Cedar Valley Hospice

“Based on hospice policy review and clinical record review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 2 of 3 sampled patients with a wound (Patients #3 and #6). Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to the hospice policy, titled Skin/Wound: Assessment and Treatment, dated 08/2024, identified physician orders for wound care treatment must be obtained and documented in the patient’s medical record. The orders may include dressing changes, including frequency and dressing type; possible wound cleaner and a type of wound fill such as gauze or alginate and cover dressing (Stage III); and/or wound cleaner, a type of wound fill and a cover dressing (Stage IV). 1. Patient #3 had a hospice admission date of 2/17/25 and received hospice services while residing in a private home. Clinical record review revealed: a. Skilled nurse visit note, dated 2/2/26 at 2:00 PM, completed by Staff J, Hospice House Registered Nurse (HH RN), included documentation wound cleaned, cleansed area, placed Mepilex, to be changed when soiled. b. Interim physician order, dated 2/4/26, apply Mepilex 4x4 (foam dressing) to open area on sacral area, change every 3 days and as needed soiled. c. Interim physician order, dated 2/6/26, Mepilex 4x4 bandage to sacral area and Silvadene topical cream twice daily and as needed. d. Interdisciplinary Group (IDG) update to the plan of care, dated 2/17/26, included interim physician orders, dated 2/4/26 and 2/6/26, but lacked documentation of orders for wound cleansing instructions. 2. Patient #6 had a hospice admission date of 8/4/25, a death date of 2/11/26, and received hospice services while residing in a private home. Clinical record review revealed: a. Skilled nurse visit note, dated 12/7/25, completed by Staff K, RN, included documentation open area left buttock, area cleansed with warm water, pat dry, applied barrier cream and Mepilex 3x3. b. Interim physician order, dated 12/7/25, Mepilex border 4x4 bandage to left buttock every 3 days and as needed. c. IDG update to the plan of care, dated 12/11/25, included interim physician order, dated 12/7/25, but lacked documentation of orders for wound cleansing instructions. The hospice failed to document physician orders for specific cleansing instructions for wound care. The above findings were reviewed with Clinical Manager and Chief Clinical Officer.”

“Based on interviews, clinical record reviews and agency policy review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 2 sampled patients who received routine home care while living in a private residence and received physician orders for controlled medications after the start of care (Patient #1). Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for who the medication was prescribed. Findings include: According to the hospice policy titled Medication Management, dated July 2016, the hospice nurse provides written and oral information to the patient/caregiver regarding the safe management and disposal of controlled drugs in a language and manner they understand when controlled substances are first ordered and documents in the patient’s clinical record the oral and written information was provided. During an interview on 4/7/26 at 4:19 PM, Staff G, Clinical Services Manager, stated patients/caregivers are educated on the disposal of controlled medications when the controlled medications are first ordered, when controlled medications are discontinued and when the patient dies. During an interview on 4/8/26 at 8:33 AM, Patient #1’s primary caregiver stated they did not recall receiving verbal or written education on the disposal of controlled medication at the time the physician first ordered the controlled medication. Patient #1 had a hospice admission date of 1/13/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial Plan of Care (POC), dated 1/13/26 to 4/12/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included physician orders for medications, but no controlled medications. b. The skilled nurse visit note, dated 1/20/26, completed by Staff I, Registered Nurse (RN), identified the patient started hydrocodone (controlled substance for pain) on 1/18/26. c. A Interdisciplinary Group (IDG) meeting note, dated 1/29/26, included physician orders (effective 1/18/26) for hydrocodone; controlled medication. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. The above findings were reviewed with the Chief Clinical Officer and the Clinical Manager.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) In clinical records in which infusions were ordered, the agency did not ensure that all flushes were documented on the medication profile and reviewed for all potential interactions. Clinical Record 25: A patient was admitted on 11/24/2024 with injectable medications of hydromorphone (pain control), haloperidol (anti-anxiety), chlorpromazine (mood-altering) with PRN (as needed) dosages. These medications were all administered through a PICC (peripherally inserted central catheter) line no saline was documented on the medication profile as of 12/12/2024 for saline flush between medications, which would be required to minimize medication reactions. The saline flushes were not listed on the medication profile as a medication nor were they listed as a treatment. During an interview on 12/11/2024 with the Director of Compliance who reviewed the record and stated that the saline had been left off of the medication profile.”

“It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care. Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative if any of them so desire; The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) In clinical records reviewed in which the community patient had an order of care for a procedure, the agency did not ensure that all care was implemented and documented according to the physician’s orders on the plan of care. Clinical Record 7: The patient was admitted on 11/01/2024 with a CADD pump and Foley catheter. The initial plan of care dated 11/04/2024 included an order for the Foley catheter to be changed monthly and PRN (as needed). The clinical record lacked documentation that the Foley catheter had been changed as of review 12/10/2024. The updated plan of care on 11/20/2024 documented that the placement of the subcutaneous (SQ) site and equipment would be changed every 10 days. There was a documented site change on 12/02/2024 (2 days late) however, there was no documented reason for the late site change. There was no documented site irritation with the dressing change. Clinical Record 20: The plan of care was updated on 12/09/2024 for skin integrity with interventions documented for the dorsal foot. The nursing visit note dated 12/06/2024 documented the nurse cleaned the foot and applied a Mepilex dressing to be changed every 3 days. There were no documented dressing changes as of the review on 12/12/2024. This was 6 days and no reason for not documenting the dressing change. The wound was documented as improving. The case manager stated that the facility changed the dressing but that this was not documented. During an interview with the Director of Compliance who reviewed the records and stated care had not been documented according to the physician’s orders.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records of community hospice patients reviewed, it was revealed that the agency did not ensure the plans of care documented all interventions for the care of the patients. Clinical Record 1: The initial nursing assessment dated 11/15/2024 documented a history of falls of 10, with unsteady gait of 5 and urinary incontinence. The initial plan of care (11/15/2024) and updated plans of care did not document any interventions for fall precautions. The instruction on admission was for non-skid shoes, moving throw rugs, and obstacles, and monitoring for risk but this was not in the care plan. It was documented that the patient was using lorazepam (anti-anxiety) and morphine (pain control) for symptom control and was a continued fall risk. Clinical Record 18: The initial plan of care was dated 10/17/2023, with documented intervention for the Foley catheter to be changed monthly and performed by skilled nursing (SN) or facility nurse. The nursing assessment dated 02/16/2024 documented that the facility nurse asked about flushing the catheter and was instructed to flush the catheter as needed. There was no documented intervention for catheter flushes as of 12/12/2024 with updated plans of care. The facility did have an order to flush the catheter. Clinical Record 20: The plan of care was updated on 12/09/2024 for skin integrity with interventions documented for the dorsal foot. It was not specific to which foot was to be treated. The intervention was documented to assess the wound for changes in pain, drainage, stage and healing but was not specific to the wound care provided. The nursing visit note dated 12/06/2024, documented that the nurse cleaned the foot and applied a Mepilex dressing to be changed every 3 days. These interventions were not documented in the plan of care. During an interview, the Director of Compliance stated that the interventions were not complete, and that new staff had completed the documentation.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. Clinical Record 7: The aide care plan dated 11/04/2024 included a task assigned for bed bath every visit and a visit frequency of 2 times a week. Updated nursing comprehensive assessment dated 11/24/2024 documented starting a subcutaneous site in the abdomen to begin an infusion of hydromorphone. This was not updated for the aide to direct that this was placed in the abdomen or what to do if the dressing was off or saturated. During an interview on 12/12/2024 with the Director of compliance who reviewed the record, and the Administrator stated that the plan did not provide direction related to the dressing and pump.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) In clinical records reviewed, for patients that had documented infusions, it was revealed that the agency did not ensure all physician orders were documented for required flushes and care. Clinical Record 25: A patient was admitted on 11/24/2024 with injectable medications of hydromorphone (pain control), haloperidol (anti-anxiety), and chlorpromazine (mood-altering) with PRN (as needed) dosages. These medications were all administered through a PICC (peripherally inserted central catheter) line. The line would require flushes of saline between medications to prevent medication interactions. There was no documented physician’s order for saline. Additionally, there was no documented order for dressing change for the PICC line. interview with the staff stated that saline was used between medications. During the interview with the Director of Compliance who reviewed the chart and stated that the orders were not documented.”