Care Initiatives Hospice - Albia

“Based on home visit observation, patient interview, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 9 of 19 sampled patients (Patients #1, #7, #8, #9, #10, #11, #12, #15 and #19). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 7. Patient #9 had a hospice admission date of 3/27/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/27/26 to 5/25/26, identified the patient had diagnoses of endometrium cancer and hypothyroidism and included active orders for levothyroxine 75 mcg daily. b. The skilled nurse comprehensive assessment, dated 3/27/26, completed by Staff H, RN, identified a drug regimen review completed but failed to identify any current drug therapy associated with lab monitoring. The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring. 8. Patient #11 had a hospice admission date of 2/21/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/21/26 to 4/21/26, identified the patient had diagnoses of unspecified severe protein calorie malnutrition, hypothyroidism and hypertensive heart disease and included active orders for Lasix 20 mg daily and levothyroxine 25 mcg daily. b. The skilled nurse comprehensive assessment, dated 2/21/26, completed by Staff D, RN, identified a drug regimen review completed but failed to identify any current drug therapy associated with lab monitoring. The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring. 9. Patient #19 had a hospice admission date of 5/21/26, a death date of 6/17/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 5/21/26 to 8/18/26, identified the patient had diagnoses of colon cancer and hypertension and included an active order for furosemide 80 mg daily. b. The skilled nurse comprehensive assessment, dated 5/21/26, completed by Staff E, RN, identified a drug regimen review completed but failed to identify any current drug therapy associated with lab monitoring. The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring. The above findings were reviewed with the Administrator and Director of Hospice Clinical Operations. 3.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included active physician orders for divalproex sodium 500 milligram (mg) daily and 1,000 mg daily, Klor-Con 10 milliequivalents (mEq) twice per day 3 days per week, Lasix 40 mg daily, levothyroxine 125 mcg daily, sodium chloride 2,000 mg twice per day and oxygen to be applied at 2 liters per nasal cannula as needed for dyspnea.b. The skilled nurse comprehensive assessment, dated 4/21/26, completed by Staff L, RN, identified that a drug regime review (DRR) was completed and no issues were identified but failed to identify any current drug therapy associated with laboratory monitoring.The hospice nurse failed to complete an accurate DRR addressing all components, including drug therapy associated with lab monitoring.c.The skilled nurse comprehensive assessment, dated 5/7/26, completed by Staff H, RN, included documentation that the patient’s oxygen level was 3 liters. The patient’s oxygen level was not at the level ordered by the physician.d.The skilled nurse comprehensive assessment, dated 5/28/26, completed by Staff F, RN, included documentation that the patient’s oxygen level was 4 liters. The patient’s oxygen level was not at the level ordered by the physician.The DRR failed to include an accurate review of all medications taken by the patient including the effectiveness of the amount of oxygen the patient required.4.Patient #8 had a hospice admission date of 6/5/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/5/26 to 9/2/26, identified the patient had a primary diagnosis of alcoholic cirrhosis of the liver with ascites and included active physician orders for spironolactone 25 mg daily, Lasix 40 mg daily and metolazone 2.5 mg daily.b. The skilled nurse comprehensive assessment, dated 6/5/26, completed by the Administrator, identified that a DRR was completed, new/changed medications identified and the medication profile updated but failed to identify any current drug therapy associated with laboratory monitoring.The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring.5.Patient #12 had a hospice admission date of 12/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/12/26 to 6/9/26, identified the patient had a primary diagnosis of cerebral atherosclerosis and included active physician orders for Lasix 40 mg daily. b. The skilled nurse comprehensive assessment, dated 12/12/25, completed by Staff E, RN, identified that a DRR was completed and no evidence of change since last review but failed to identify any current drug therapy associated with laboratory monitoring.The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring.6.Patient #15 had a hospice admission date of 8/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/30/25 to 1/27/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included active physician orders spironolactone 25 mg daily and potassium 20 mEq daily.b. The skilled nurse comprehensive assessment, dated 10/30/25, completed by Staff D, RN, identified that a DRR was completed and no evidence of change since last review but failed to identify any current drug therapy associated with laboratory monitoring.The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring. According to the agency’s policy titled Medication-Drug Regimen Review, dated 3/23/26, an initial drug regimen review (DRR) is completed within five days of admission and ongoing with medication changes, changes in patient condition and/or at a minimum of every 15 days. The DRR includes a review of the patient’s medications for side effects of drug therapy, lab monitoring for associated drug therapy, actual or potential drug interactions, duplicate drug therapy and effectiveness of drug therapy. During an interview on 7/29/26 at 10:10 AM, the Clinical Manager, stated DRR’s are completed on admission and at every Interdisciplinary Group (IDG) meeting. They are reviewed with the Medical Director and Pharmacist and documented in the communication notes. 1.Patient #1 had a hospice admission date of 7/30/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 5/26/26 to 7/24/26, identified the patient had a primary diagnosis of Parkinson’s disease and included physician orders for levothyroxine 100 micrograms (mcg) daily. b. The skilled nurse comprehensive assessment, dated 7/30/25, completed by Staff O, Registered Nurse (RN), identified a drug regimen review completed but failed to identify any current drug therapy associated with lab monitoring. The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring. 2. Patient #10 had a hospice admission date of 1/31/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 5/1/26 to 7/29/26, identified the patient had a primary diagnosis of Hypertensive heart disease with heart failure and included physician orders for levothyroxine 137 mcg daily. b. The skilled nurse comprehensive assessment, dated 1/31/26, completed by Staff L, RN, identified a drug regimen review completed but failed to identify any current drug therapy associated with lab monitoring. The hospice nurse failed to complete an accurate drug regimen review addressing all components, including drug therapy associated with lab monitoring.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the hospice plan of care included orders for all necessary medications and treatment to meet the needs of the patients for 2 of 3 sampled patients (Patients #3 and #4) with home observation visits in a private residence. Failure to ensure the plan of care included orders for all medications and treatments necessary to meet the needs of the patients placed patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patient. Findings include: 2. Patient #3 had a hospice admission date of 9/18/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26, identified the patient had a primary diagnosis of malignant neoplasm of the pancreas and included physician orders for skilled nurse visits, medications and treatments. b. The hospice medication list, dated 7/29/26, identified the medication order for Tizanidine 2 mg every 8 hours as needed for muscle spams. c. During an observational home visit on 7/29/26 at 1:00 PM with Staff RN, the following discrepencies noted.1) Butalbital-APAP (acetaminophen)-caffiene 50/325/40 mg, 1 tablet two times a day as needed for headaches. The medication filled on 10/17/25 and not listed on the POCs. 2) Tizanidine 2 mg every 8 hours as needed for muscle spams listed on the POCs. During an interview with the patinet during the same home visit they stated the medication not available and no longer used for several months. c. The IDG updates to the POC, dated 6/2, 6/16, 6/30, 7/7 and 7/21/26 failed to include butalbital-APAP-caffiene as a medication and failed to discontinue tizanidine. The hospice failed to include all current medications on the plan of care necessary to manage the patient’s symptoms. The above findings were reviewed with the Director of Hospice Clinical Operations and the Administrator. According to the hospice policy titled Plan of Care, dated 2/1/2023, the patient’s plan of care specifies the care and services necessary to meet the needs of the patient, caregiver and family as identified in the comprehensive assessment and reassessments of the patient. The content of the plan of care includes, but is not limited to the interventions to facilitate the management of pain and symptoms, drugs and treatment necessary to meet the needs of the patient and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #4 had a hospice admission date of 10/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plans of Care (POC), dated 4/25/26 to 6/23/26 and 6/24/26 to 8/22/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included physician orders for skilled nurse visits, medications and treatments. b. The skilled nurse comprehensive assessments, dated 6/8/26 and 7/8/26, completed by Staff H, Registered Nurse (RN), identified the patient takes Tums (Calcium Carbonate) for heartburn. c. The Interdisciplinary Group (IDG) updates to the POC, dated 6/9/26 and 7/14/26 failed to include calcium carbonate as an active medication/treatment the patient utilizes for symptom control. During an interview on 8/4/26 at 9:35 AM, the Administrator confirmed the POC failed to include calcium carbonate as an active medication/treatment the patient utilizes for heartburn. The hospice failed to include all medications/treatments on the plan of care necessary to manage the patient’s symptoms.”

“Based on clinical record review, facility document review, agency policy and staff interview, the hospice failed to show any action taken to initiate, improve and/or sustain performance improvement for bereavement for 1 of 3 sampled patients (Patient #17) that died. Failure to show action taken to improve and/or sustain performance improvement as part of a developed Quality Assurance and Performance Improvement (QAPI) program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI) Program Data, dated 3/11/26, through the use of family satisfaction surveys, data is collected regarding patient and family care outcomes related to the following measure effective grieving. The QAPI Committee utilizes results of data analyses to identify negative trends and performance improvement opportunities. Priorities for data collection and measurement activities are based on identification of negative trends, staff and leadership input, and areas that require more focused and intensive review and analysis. During an interview on 8/5/26 at 9:07 AM, the Director of Hospice Clinical Operations reported that a Performance Improvement Project (PIP) should have started after the agency received the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for Patient #17. Patient #17 had a hospice admission date of 8/30/24 and a death date of 9/1/24 and received hospice services while residing in a private home. Clinical record review revealed:a. The plan of care (POC), dated 8/30/24 to 11/27/24, identified the patient had a primary diagnosis of Hypertensive heart disease with heart failure and included orders for skilled nurse, social work and spiritual counseling. b. Review of the CAHPS survey, dated 12/18/24, identified that the family of Patient #17 received no bereavement support from hospice. Follow up for the CAHPS suvey identified, the agency Administrator called Patient #17’s family to offer bereavement follow-up that Staff P, Social Worker and Bereavement Coordinator, would provide, which was accepted by the family. c.The Bereavement Care Plan PIP, dated 8/4/25, identified that Staff P was terminated for not following through with services. The PIP was initiated 7 months following the return of the Hospice CAHPS, dated 12/18/24. The agency failed to initiate a PIP in a timely manner after receiving a negative family satisfaction survey. The above findings were reviewed with the Director of Hospice Clinical Operations.”

“Based on staff interview, clinical record reviews and hospice agency policy review, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 4 of 12 sampled patients receiving hospice aide services (Patients #4, #7, #9 and #10).Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: 4. Patient #10 had a hospice admission date of 1/31/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/1/26 to 7/29/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included orders for skilled nurse and hospice aide services.b. The undated hospice aide care plan included aide instructions to ambulate with assist x 1 gait belt and walker, recognize and report any changes in patient’s skin condition to nurse and charge nurse, bring patient coffee from Scooters twice weekly, encourage fluids, regular diet with thin liquids, assist to toilet, change adult diapers when soiled, incontinent care when incontinent, lotion bilateral upper and lower extremities, patient is cognitively and functionally able to make choices, take patient outside for 15 minutes in wheelchair when temperature above 70 degrees and wash hands and face.c. The hospice aide visit note, dated 6/23/26, completed by Staff N, Hospice Aide, documented “not required today”: lotion to bilateral upper and lower extremities and wash hands and face. The hospice aide failed to complete tasks as instructed by the RN assignment. The above findings were reviewed with the Director of Hospice Clinical Operations and the Administrator. 2. Patient #4 had a hospice admission date of 10/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 6/24/26 to 8/22/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included orders for skilled nurse and hospice aide services.b. The undated hospice aide care plan included aide instructions to apply lotion to arms and legs, change sheets once weekly, change adult diapers if incontinent, fill humidification bottle on oxygen concentrator with sterile water each visit, clean bathroom after patient care, make patient bed, perform partial bed bath if patient refuses shower, provide shower in shower chair, trim any long or uneven toenails, trim any long or uneven fingernails, load the dishwasher if dirty dishes present, vacuum the front room once a week, put dirty clothes in the washing machine and standby assist with cane when ambulating.c. The hospice aide visit note, dated 7/24/26, completed by Staff G, Hospice Aide, documented putting oxygen on the patient. The hospice aide failed to complete tasks only as instructed by the RN assignment. 3. Patient #9 had a hospice admission date of 3/27/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/26/26 to 7/24/26, identified the patient had a primary diagnosis of endometrium cancer and included orders for skilled nurse and hospice aide services. b. The undated hospice aide care plan included aide instructions to change adult diapers when incontinent, provide incontinent care when incontinent, file any long or uneven fingernails, shampoo patient, shower patient in shower chair once per week, apply lotion to patient’s upper and lower extremities, trim any long or uneven fingernails, set up so patient can brush teeth and wash patient’s hands and face if refuses shower. c. The hospice aide visit note, dated 5/26/26, completed by Staff G, Hospice Aide, documented not required today to the tasks of shampoo and shower patient in a shower chair once per week. d. The hospice aide visit note, dated 5/28/26, completed by Staff G, Hospice Aide, documented already completed this week to the tasks of shampoo and shower patient in a shower chair once per week. e. The hospice aide visit note, dated 6/9/26, completed by Staff G, Hospice Aide, documented performing a bed bath and applying a shampoo cap. The hospice aide failed to complete tasks as instructed by the RN assignment. 1.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The plan of care (POC), dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included orders for skilled nurse and aide services. b. The hospice aide care plan, dated 4/22/26, included aide instructions to provide shower in shower chair once per week. This task was removed 6/1/26.c. The hospice aide visit note, dated 7/8/26, completed by Staff G, Hospice Aide, documented that a shower was given.The hospice aide failed to complete tasks only as instructed by the RN assignment.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 6 of 19 sampled patients (Patients #1, #3, #6, #10 #12 and #15). Failure to ensure all documentation was completed, dated, and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: 6. Patient #6 had a hospice admission date of 1/21/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker and massage therapy services. b. The massage therapy visit notes, dated 6/10/26 and 6/24/26, completed by Staff M, Massage Therapist, lacked the date the massage therapist signed the visit notes. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. The above findings were reviewed with the Administrator and Director of Hospice Clinical Operations. 4. Patient #12 had a hospice admission date of 12/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/12/26 to 6/9/26, identified the patient had a primary diagnosis of cerebral atherosclerosis and included orders for skilled nurse, social work, volunteer, spiritual counseling and massage therapy services. c. The skilled nurse visit note, dated 5/27/25, completed by Staff E, RN, included date of completion on 6/9/26, 3 days after the visit and 12 days late per hospice policy. The RN failed to complete documentation in a timely manner according to hospice policy. d.The massage therapy visit notes, dated 6/10/26, 6/24/26 and 7/15/26, completed by Staff M, Massage Therapist, lacked the date the massage therapist signed the visit notes.The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. 5. Patient #15 had a hospice admission date of 8/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 10/30/25 to 1/27/26 and 1/28/26 to 4/27/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, aide, social work, volunteer, music therapy, spiritual counseling and massage therapy services. b.The massage therapy visit notes, dated 12/10/25, 12/17/25 and 1/14/26 and 1/28/26, completed by Staff M, Massage Therapist, lacked the date the massage therapist signed the visit notes.The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. According to the hospice policy titled, Clinical Records, dated 2/1/23, all entries into the clinical record must be legible, clear, complete and appropriately authenticated and dated in accordance with hospice policy and accepted standards of practice. According to the hospice policy titled, Patient Record Integrity, dated 12/5/23, all visit information, including notes and visit documentation, is ideally completed/locked down during the patient visit but no later than one week from the date of service. During an interview on 7/29/26 at 10:10 AM, the Clinical Manager stated authentication requires staff hame, title and date. She further stated hospice policy, staff have 7 days to complete documentation. 1.Patient #1 had a hospice admission date of 7/30/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plans of Care (POCs), dated 5/26/26 to 7/24/26 and 7/25/26 to 9/22/26, identified the patient had a primary diagnosis of Parkinson’s disease and included orders for skilled nurse and social worker services. b. The skilled nurse note at recertification, dated 7/27/26, completed by Staff F, Registered Nurse (RN), included date of completion on 7/27/26, 10 days after date of service and 3 days late per hospice policy. The RN failed to complete documentation in a timely manner according to hospice policy. 2. Patient #3 had a hospice admission date of 9/18/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26, identified the patient had a primary diagnosis of malignant neoplasm of the pancreas and included orders for skilled nurse, social worker, massage therapy and home health aide services. b. The skilled nurse note at recertification, dated 7/2/26, completed by Staff F, RN, included date of completion on 7/10/26, 8 days after date of service and 1 days late per hospice policy. The RN failed to complete documentation in a timely manner according to hospice policy. c. The massage therapy visit notes, dated 6/10, 6/24 and 7/15/26, completed by Staff M, Massage Therapist, included staff signature and staff credentials but lacked date of signature completion. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. 3. Patient #10 had a hospice admission date of 1/31/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/1/26 to 7/29/26, identified the patient had a primary diagnosis of hypertensive heart disease with heart failure and included orders for skilled nurse, social worker, massage therapy and home health aide services. b. The massage therapy visit notes, dated 6/10, 6/24 and 7/15/26, completed by Staff M, Massage Therapist, included staff signature and staff credentials but lacked date of signature completion. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice.”