Above & Beyond Hospice Care

“Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 1 of 5 sampled patients. (Patient #1) Failure to follow the patient’s Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice policy, titled Hospice – Care Planning Process, dated 12/11/25, identified the IDG ensures that all services, including contracted services, are provided in a safe and effective manner through on-going communication, observation, planning, chart review, quality assurance activities and patient/family satisfaction survey results. Patient #1 had a hospice admission date of 4/28/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG update to Plan of Care, dated 6/25/26, included primary hospice diagnosis of Alzheimer’s disease and orders for massage therapy services 1 visit every 2 weeks for 8 weeks. b. Massage therapy visit note, dated 7/2/26, completed by Staff H, Massage Therapist, included documentation of a completed visit and patient quickly relaxed during massage and fell asleep. c. Massage therapy visit note, dated 7/22/26, completed by Staff H, Massage Therapist, included documentation of a completed visit and no signs of pain after massage. 21 days or 3 weeks after the last visit. During an interview on 8/19/26 at 9:30 AM, Staff C, Home Health Clinical Manager, reviewed clinical record and confirmed massage therapy visit was made 3 weeks after the last visit instead of 2 weeks as ordered. The massage therapist failed to complete a visit every two weeks as ordered. The above findings were reviewed with Staff C, Home Health Clinical Manager and Staff B, Business/Facilities Manager.”

“Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted that hand hygiene guidelines were not followed. For example, in hospice home visit #3 the hospice aide was observed applying hand sanitizer to his hands and then waving his hands in the air. This was observed by the hospice director present on the visit. Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted that bag technique was not followed per agency policy which stated that the bag be placed on a clean dry surface in the home. For example, in hospice home visit #2 the nurse was observed placing her backpack containing nursing supplies onto the seat of a chair which was ripped and torn in multiple areas as if slashed with a sharp object. This was observed by the director of hospice present on the visit.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group performed an accurate and complete drug regimen review for 4 of 19 sampled patients (Patients #2, #12, #15, and #18). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. 3. Patient #12 had a hospice admission date of 2/9/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The Plans of Care, dated 2/9/24 to 5/8/24 and 5/9/24 to 8/6/24, included physician orders for miralax and senna (bowel medications) and finasteride and myrbetriq (benign prostatic hypertrophy medications). b. The Interdisciplinary Group meeting notes, dated 2/14/24, 4/10/24, 4/24/24 and 5/22/24, included a drug regimen review that identified no duplicate drug therapy. The drug regimen reviews failed to identify the duplicate bowel and benign prostatic hypertrophy medications. 4. Patient #15 had a hospice admission date of 7/19/23, a revocation date of 9/27/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 7/19/23 to 10/16/23, included physician orders for lunesta and trazodone (sleep medications) and sertraline and seroquel (antidepressant medications). b. The Interdisciplinary Group meeting notes, dated 7/26/23, 8/9/23, 8/22/23, 9/6/23 and 9/20/23, included a drug regimen review that identified no duplicate drug therapy. The drug regimen reviews failed to identify the duplicate sleep and antidepressant medications. The Administrator received the above findings. Hospice staff provided no further information prior to the end of the survey. Findings include: The hospice’s policy, titled Hospice - Care Planning Process, dated 4/1/2020, identified upon completion of the initial assessment visit and prior to providing care, the hospice develops the Plan of Care with input from the physician(s) and IDG (interdisciplinary group), in collaboration with patient and family. The IDG completes the Comprehensive Assessment in consultation with the attending physician with five (5) calendar days of the notice of hospice election. The content of the comprehensive assessment includes: a drug profile including over the counter drugs, herbal supplements, and alternative treatments. The drug profile will be reviewed for: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring. 1.Patient # 2 had a start of care date 2/26/24, and received hospice services in the home. a. During a home observation visit, 6/3/24 at 12;30 pm with Staff F, RN (Registered Nurse), The patient’s caregiver indicated they were using A/D ointment on patient’s coccyx on a regular basis, the caregiver also indicated they were using good feet lotion daily on patients feet. b. The Plan of Care, dated 5/26/23-8/23/23, included orders for medications, but lacked orders for the A/D ointment and the good feet lotion. c. The Medication Profile, last updated on 5/6/24, failed to identify the A/D ointment and the good feet lotion. d. During an interview with Staff F on the home observation visit, she acknowledged the Medication Profile failed to include the A/D ointment and the good feet lotion. e. The drug regiment review completed on 5/22/24 failed to include these medications as part of a comprehensive review of all medications. 2. Patient #18 had a start of care date of 6/29/23, a death date of 7/723 and received hospice services in a skilled nursing facility. a. Clinical record review identified the Initial IDG (Interdisciplinary group) conference was held on 7/5/23, The IDG failed to address an initial drug regimen review as part of the initial comprehensive assessment.”

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to document required hospice aide supervision every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 2 of 5 sampled patients (Patients #13 and #15) with hospice aide services for 14 days or longer. Failure to ensure the supervision of hospice aide by registered nurses completed according to regulation increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: According to the hospice policy, titled Hospice - Supervision of Hospice Health Aides, dated 10/27/23, supervision is completed by a registered nurse in the patient’s care setting at least every 14 days. 1. Patient #13 had a hospice admission date of 2/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 2/23/24 to 5/22/24, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 4/8/24 and 4/23/24, included documentation the nurse supervised the hospice aide, 15 days apart, (1 day late). c. The skilled nursing visit note, dated 4/15/24, failed to include documentation the nurse supervised the hospice aide. The hospice failed to document aide supervision every 14 days. 2. Patient #15 had a hospice admission date of 7/19/23, a revocation date of 9/27/23, and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 7/19/23 to 10/16/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 8/8/23 and 8/23/23, included documentation the nurse supervised the hospice aide, 15 days apart, (1 day late). c. The skilled nursing visit notes, dated 8/11/23, 8/15/23 and 8/18/23, failed to include documentation the nurse supervised the hospice aide. The hospice failed to document aide supervision every 14 days. The Administrator received the above findings.”

“Based on review of written contracts and staff interview, the hospice failed to ensure the written agreement between hospice and durable medical equipment was complete and accurate for 2 of 4 services under contract. Failure to have complete and accurate contracts for hospice services increases the potential that hospice management and oversight could fail to occur and the patient would not receive services as specified on the plan of care. Findings include: Review of the contract between hospice and their pharmacy dated 2/7/24 identified the contract was missing verbiage in the following provisions: Hospice retains administrative management. Hospice retains financial management. Hospice retains oversight of staff and services. All services authorized by the hospice. 2. Review of the contract between hospice and their durable medical equipment provider dated 2/1/23 identified the contract was missing verbiage in the following provisions: Hospice retains administrative management. Hospice retains financial management. Hospice retains oversight of staff and services. All services authorized by the hospice. All services are furnished in a safe and effective manner by qualified personnel. All services delivered in accordance with the patients plan of care. In an interview on 6/3/24 at 8:10 AM, the Administrator reported that the pharmacy contract is used for Home Health mostly but understands the verbiage needs to be here if using for hospice. The above findings were reviewed with the Administrator, Business Office Coordinator, and Hospice Admission Coordinator.”

“Based on clinical record review, nursing home clinical record review and hospice staff interview, the hospice failed to ensure the hospice medication list matched the nursing home medication administration record for 1 of 1 sampled patients (Patient #1) with home observation visit in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: During an interview on 5/29/24 at 10:00 AM, Staff D, Hospice Admission Coordinator reported the hospice registered nurses try to review the medication administration records every visit for patients in nursing homes. Patient #1 had a hospice admission date of 4/12/24 and received routine hospice services while residing in a nursing home. On 5/28/24 at 11:45 AM, during a home visit observation with Staff E, RN (registered nurse) the surveyor received a copy of the medication administration record. The medication administration record included physician orders for acetaminophen 650 milligrams (mg) by mouth every 4 hours as needed for pain or fever effective 3/21/22 and enema disposable enema insert 1 suppository rectally every 24 hours as needed for constipation effective 6/1/21. Clinical record review revealed: a. the hospice medication list included physician order for acetaminophen 325 mg tablets 2 tablets every 6 hours as needed for pain or fever. b. the hospice medication list lacked documentation of a physician order for enema/rectal suppository. The Administrator received the above findings.”