Helping Hands Hospice

“Based on record review, policy and procedure and staff interviews, it was determined that the hospice failed to protect and promote the exercise of patient’s rights by not following one-hour response time for one patient (P) (P11) of three patients reviewed from call log. Specifically, Licensed Practical Nurse (LPN) LPN AA failed to provide medication as ordered within one hour of response time. Findings included: Review of undated policy titled ”Helping Hands Hospice Policy,” revealed:“Purpose:To ensure all hospice nurses provide safe, timely, compassionate, and evidence-based pain management that promotes patient comfort, dignity, symptom relief, and quality ofPolicy StatementAll hospice nursing staff are responsible for assessing pain promptly, implementing ordered interventions, monitoring effectiveness, documenting findings, educating caregivers, and notifying providers when pain is not controlled.Pain Must be addressed immediately. We have up to an hour to visit and resolve any pain related concerns.” Review of agency document titled “Your Rights and Responsibilities, Patient / Family Rights,” revealed:“B. The following rights shall be guaranteed to the patient, and, at a minimum, the Hospice shall provide the patient with a written and oral explanation of these rights:1. Hospice Services.l. Right to receive effective pain management and symptom control related to condition of the terminal illness.” Review of the agency’s call log revealed the facility called LPN AA on 01/10/2026 to report P11 was screaming in pain and the facility was out of syringes to administer morphine (used for pain). Review of visit note by LPN AA, dated 01/12/2026, revealed a visit was not made until 01/11/2026 at 11:00 AM. A telephone interview was conducted on 04/27/2026 at 4:10 PM with LPN AA, who confirmed that she did not attempt to get syringes until the next day. During an in-office interview on 04/28/2026 at 11:00AM, the Administrator confirmed the agency failed to respond to reports of P11 screaming in pain until the next day.”

“Based on review of agency policies and procedures, clinical record reviews, and staff interviews it was determined that the agency’s governing body failed to organize, manage, or administer its resources to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions. Specifically, the hospice failed to provide one patient (P) (P11) with nursing services within one hour of notification of patient being in pain, and provide syringes needed for pain management. Findings included: Review of the undated policy titled “Governing Body Authorization,” reveals the following:“The Governing Body assumes full legal responsibility for approving, implementing, and monitoring the policies and procedures.The Governing Body is responsible for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained.Review of the undated policy titled “On call services,” revealed the following:Purpose: To ensure the availability of nursing services for hospice patients twenty-four hours per day, seven days a week.” Review of the undated policy titled “Helping Hands Hospice Policy,” revealed the following:“Purpose: To ensure all hospice nurses provide safe, timely, compassionate, and evidence-based pain management that promotes patient comfort, dignity, symptom relief, and quality of life.Policy statementAll hospice nursing staff are responsible for assessing pain promptly, implementing ordered interventionsPain must be addressed immediately. We have up to an hour to visit and resolve any pain related concerns.” Review of the agency’s call log dated 01/10/2026, revealed the facility called Licensed Practical Nurse (LPN) AA to report P11 was screaming in pain and the facility was out of syringes to administer morphine. Review of visit note by LPN AA, dated 01/12/2026, revealed a visit was not made until 01/11/2026 at 11:00 AM. A telephone interview was conducted on 04/27/2026 at 4:10 PM with LPN AA, who revealed the agency keeps a supply of syringes in the supply room but that she did not take syringes to the patient until the next day. During an in-office interview on 04/28/2026 at 11:00 AM, the Administrator confirmed the agency failed to send a nurse to address and manage pain within the one-hour response time.”

“Based on policy titled “Governing Body Authorization,” clinical record reviews, on-call logs, and staff interview, it was determined the agency failed to comply with the nursing services’ one-hour response time when notified of a patient experiencing a crisis or change in condition for one patient (P) (P11) of two patients sampled from the on-call log. The findings included: Review of the policy titled “Governing Body Authorization” revealed the following: “5. (Administrator) – Role will be to ensure nurses are following state regulations, medication review, and management.” Review of the agency on-call binder revealed that on 01/10/2026, Assisted Living Facility (ALF) called to report patient (P) (P11) was screaming in pain, and the facility was out of syringes needed to administer morphine. Review of the clinical record for P11 revealed Licensed Practical Nurse (LPN) AA failed to visit until the next day, 01/11/2026 at 11:00 AM. The clinical record failed to reveal documentation of communication with the interdisciplinary team regarding concerns of P11’s unmanaged pain or need for syringes. On 4/27/2026 at 4:10 PM, a telephone interview was conducted with LPN AA, who revealed the agency keeps a supply of syringes in the supply room but that she did not attempt to get syringes until the next day. LPN AA confirmed that the physician and RN were not notified that P11 was in pain and needed syringes and that a nursing visit was not made within the one-hour response time. On 04/28/2026 at 11:00 AM, an interview was conducted with the Administrator, who confirmed the agency failed to send a nurse to address and manage pain within the one-hour response time.”

“Based on record reviews, policy review, and staff interviews, it was determined that the agency failed to manage patient’s pain and symptoms related to the terminal illness. Findings included: Review of agency document titled “Your Rights and Responsibilities, Patient / Family Rights,” revealed:“B. The following rights shall be guaranteed to the patient, and, at a minimum, the Hospice shall provide the patient with a written and oral explanation of these rights:1. Hospice Services.l. Right to receive effective pain management and symptom control related to condition of the terminal illness.” Review of the agency’s call log revealed the facility called Licensed Practical Nurse (LPN) AA on 1/10/2026 to report P11 was screaming in pain and the facility was out of syringes to administer morphine (used to treat pain). Review of visit note by LPN AA, dated 1/12/2026, revealed a visit was not made until 1/11/2026 at 11:00 AM. Cross reference to L0500 relating to Patient’s Rights”

“Based on policy titled “HOSPICE PLAN OF CARE,” clinical record reviews, home observation, and staff interview, it was determined that the agency failed to develop a care plan which includes all services necessary for the palliation and management of the terminal illness and related conditions for two patients (P) (P6, P8) of 14 sampled patients. Findings included: Review of undated policy titled HOSPICE PLAN OF CARE,” reveals the following:Policy: A plan of care (POC) shall be developed by the interdisciplinary team within five (5) days of admission, approved by a physician, and updated as needed, and shall include the care, treatment, and services related to the needs of the patient and maintained in the patient record.Procedure:1. The plan of care must include an assessment of the patient’s needs and identification of services, including the management of discomfort and symptom relief. The plan of care shall state in detail the scope and frequency of services needed to meet the patient’s and family’s needs.2. All interdisciplinary team members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician and/or medical director, the patient/patient representative and primary care giver.3. Using the data obtained during the initial and ongoing hospice assessments, the interdisciplinary team members develop a list of patient problems and needs with corresponding goals, interventions, and anticipated target dates for reaching those goals. 1. Review of Registered Nurse (RN) Hospice Initial Assessment note dated 06/20/2025 for P6 revealed that patient has a Foley catheter (A Foley catheter is a semi-flexible plastic tube. One end is inserted into the bladder, and the other end is attached to a bag that collects urine. It is used when you cannot urinate normally). Review of plan of care for P6 states the following: Change foley catheter as ordered every 30 days and as needed if leakage or blockage occurs.The plan of care failed to reveal complete order for Foley catheter care, specifically the size of the catheter, the size of the balloon and the exact type and amount of solution to inflate the balloon to maintain the catheter in the bladder. 2. On 04/28/2026 at 9:30 AM, during home observation with P8, it was revealed that P8 has a Foley catheter. The Plan of care for P8 failed to reveal orders for Foley catheter care/management. During an in-office interview on 4/29/2026 at 1:00 PM, the Administrator confirmed that the agency failed to include Foley catheter orders for P6 and P8 in the plan of care.”

“Based on record reviews, policy and procedure, and staff interview, it was determined that the agency failed to ensure that the care and services are provided in accordance with the plan of care for three patients (P) (P4, P6 and P8) of 14 sampled patients. Findings included: Review of undated policy titled HOSPICE PLAN OF CARE,” reveals the following:Policy: A plan of care (POC) shall be developed by the interdisciplinary team within five (5) days of admission, approved by a physician, and updated as needed, and shall include the care, treatment, and services related to the needs of the patient and maintained in the patient record.Procedure:1. The plan of care must include an assessment of the patient’s needs and identification of services, including the management of discomfort and symptom relief. The plan of care shall state in detail the scope and frequency of services needed to meet the patient’s and family’s needs.2. All interdisciplinary team members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician and/or medical director, the patient/patient representative and primary care giver.3. Using the data obtained during the initial and ongoing hospice assessments, the interdisciplinary team members develop a list of patient problems and needs with corresponding goals, interventions, and anticipated target dates for reaching those goals. 1. Review of the Registered Nurse (RN) comprehensive Assessment note dated 01/07/2026 for P6 revealed that RN changed indwelling catheter using 18 French (catheter size) with 10 cc (balloon size) of sterile water added to balloon. Review of RN comprehensive Assessment note dated 04/09/2026 for P6 revealed that RN changed indwelling catheter using 18 French (catheter size) with 12 cc (balloon size) of sterile water added to balloon. Plan of care failed to reveal specific Foley Catheter order for P6. Agency provided Foley care without physician’s order. 2. Review of plan of care dated 02/11/2026 for P4 revealed the following: Wound care: Stage 3 pressure ulcer to right hup. Clean with wound cleanser/normal saline; pat dry, cover with mepilex /allevyn (soft, absorbent silicone foam dressing) /allevyn (advanced, absorbent, and breathable foam) patch, start date 02/13/2026. Review of Skilled Nursing Visit note dated 02/13/2026 and 02/18/2026, failed to reveal that wound care was provided to P4. Record review for P4 failed to reveal wound assessment/measurements and treatments to wound as per plan of care. 3. Review of plan of care dated 04/19/2026 for P8 reveal the following: Assess pressure ulcer status including signs and symptoms of healing and complications per plan of care for diagnosis of impaired skin integrity. Perform pressure ulcer care, clean wound area with wound cleanser, pat dry. Perform wound care dressing change: cover cleaned dry with Allevyn dressing. Review of Skilled Nursing visit notes dated 04/19/2026, 04/21/26, 04/22/2026, and 04/24/2026 for P8, failed to reveal that wound assessments and wound care was provided to P8. Record review for P8 failed to reveal wound assessment/measurements and treatments to wound as per the plan of care. Agency failed to reveal that P4 and P8’s wound was assessed and treated as per plan of care. During an in-office interview on 04/29/2026 at 1:00 PM, the Administrator confirmed that the agency failed to include complete foley catheter orders for P6 in the plan of care. The Administrator confirmed that the agency failed to follow plan of care for wound care for P4 and P8. The administrator stated that the clinical record failed to reveal wound measurements and wound treatments for P4 and P8.”

“Based on review of policy titled “Bereavement Services,” record reviews, and staff interview, it was determined the agency failed to develop a bereavement plan of care that reflects the needs of the bereaved with specific bereavement services and frequencies for two patients (P) (P11, P12), of two sampled bereavement records. Findings included: Review of undated policy titled “Bereavement Services” revealed the following:“Policy:Bereavement services are provided for at least 13 months following the death of the patient.4. Factors which may affect an individual’s/family’s ability to cope with the patient’s death shall be addressed and included in the bereavement plan of care.5. After the death has occurred, hospice updates the initial bereavement assessment and the interdisciplinary team discusses the patient’s death.12. A bereavement file will be kept on the patient’s family or caregiver. Each file will contain the following information:c. Bereavement assessmentsd. A bereavement plan of caree. Clinical notes and/or letters sent to the bereaved.16. The patient’s medical record contains the bereavement file, assessments and clinical notes.” Record reviews revealed the date of death for P11 as 01/20/2026. The clinical record failed to reveal an updated bereavement assessment or a bereavement plan of care. Record reviews revealed the date of death for P12 as 11/22/2025. The clinical record failed to reveal an updated bereavement assessment or a bereavement plan of care. On 04/28/2026 at 2:20 PM, an interview was conducted with the Administrator, who revealed that the agency’s chaplains are responsible for providing bereavement care. The Administrator confirmed that all bereavement documentation had been provided for P 11 and P 12.”

“Based on review of agency’s policies and procedures, record reviews, and staff interviews, it was determined the hospice failed to optimize comfort and dignity consistent with the patient’s needs and goals. Specifically, the agency failed to provide syringes needed to administer pain medication of one patient (P) (P11), of three patients reviewed. Findings included: Review of the undated policy titled “Helping Hands Hospice Policy,” revealed the following:Purpose: To ensure all hospice nurses provide safe, timely, compassionate, and evidence-based pain management that promotes patient comfort, dignity, symptom relief, and quality of life.Policy statementAll hospice nursing staff are responsible for assessing pain promptly, implementing ordered interventionsPain must be addressed immediately. We have up to an hour to visit and resolve any pain related concerns. Review of the agency’s call log dated 01/10/2026, revealed the facility called LPN AA to report patient (P) (P11) was screaming in pain and the facility was out of syringes to administer morphine (opioid used to treat moderate to severe pain). Review of visit note by LPN AA, dated 01/12/2026, revealed a visit was not made until 01/11/2026 at 11:00 AM. A telephone interview was conducted on 04/27/2026 at 4:10 PM with LPN AA, who revealed the agency keeps a supply of syringes in the supply room but that she did not attempt to get syringes until the next day.”