Aspen Hospice

“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. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1 : The patient elected the hospice benefit on 09/18/2024 for a diagnosis of chronic obstructive pulmonary disease. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (Personnel Record 7) on 08/20/2025, the hospice medication profile, printed on 08/19/2025 was compared with the ALF medication profile (printed on 08/20/2025). The following medication was listed on the hospice medication list that was not on the ALF list: Polymyxin eye drops, 4 times daily (ordered 05/09/2025). The following discrepancies were noted on the lists: Hospice had two medications without specific instructions: Senna Plus, take 1 capsule as needed (ordered 09/27/2024), ALF had daily as needed (ordered 01/16/2025); Guaifenesin 100 mg/5ml, 20 ml as needed (ordered 04/10/2025), ALF had every 4 hours as needed (ordered 04/10/2025). Home Visit 2 : The patient elected the hospice benefit on 03/27/2025 for a diagnosis of heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Spiritual Counselor (Personnel Record 6) on 08/20/2025, the hospice medication profile, printed on 08/19/2025 was compared with the ALF medication profile (printed on 08/20/2025). The following discrepancies were noted on the lists: Hospice had Sildenafil 25 mg (ordered 05/07/2025) versus ALF Sildenafil 20 mg (ordered 07/28/2025); Hospice had Tamsulosin 0.4 mg 1 capsule daily (ordered 03/27/2025) versus ALF Tamsulosin 0.4 mg 2 capsules daily (ordered 07/28/2025). Home Visit 3 : The patient elected the hospice benefit on 01/24/2025 for a diagnosis of unspecified protein calorie malnutrition. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (Personnel Record 4) on 08/21/2025, the hospice medication profile, printed on 08/19/2025 was compared with the ALF medication profile (printed on 08/21/2025). The following medication was listed on the hospice medication list that was not on the ALF list: Ondansetron 4 mg, take one tablet every 4 hours as needed (ordered 01/31/2025). The following supplement was listed on the ALF list and not on the hospice list: Ensure, take 1 can daily as needed (ordered 01/29/2025). A joint clinical record review and interview were conducted with the Director of Nursing on 08/21/2025 during which the medication discrepancies were confirmed, and it was stated “we will have them corrected immediately.””

“It is required that 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, observation, and interview. In 6 of 14 (43%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1/ HOME VISIT 1: The hospice aide care plan dated 03/12/2025 included the following relevant tasks: “stand by assistance with ambulation, bathing (shower), shampoo (shower), hair care, oral care, dressing, will report unusual findings to RN (registered nurse), observe/report changes in condition to RN.” All tasks were to be completed every visit. Aide visit frequency of twice weekly. The initial nursing assessment dated 09/18/2024 noted the patient to be “oxygen dependent on 2 liters per minute of supplemental oxygen.” During the home visit conducted on 08/20/2025 the Hospice Aide (Personnel Record 7) was observed removing the patient’s oxygen and placing it on the bathroom counter. When the patient was in the shower, she began coughing and the aide responded, “we’d better put your oxygen back on since you are coughing.” The hospice aide plan of care did not include instructions to the aide on if the oxygen could be removed during cares. CLINICAL RECORD 2: The hospice aide care plan dated 03/27/2025 included the following relevant tasks: “bathing-shower, do not remove oxygen, dressing, shampoo, stand by assistance.” Aide visit frequency of twice weekly with all tasks were to be completed every visit unless otherwise specified. A nursing visit dated 04/17/2025 noted “Apply Medi-honey. Cover with Mepilex border or non-adherent dressing. May provide edema support with 2-layer Coban wrap.” A nursing visit date 06/23/2025 noted “Hospice RN to provide wound care to left posterior calf 2x a week and prn (as needed) for dressing failure. Wound care as follows. Clean with normal saline and apply Mepilex border.” A nursing visit dated 08/11/2025 noted “Left knee abrasion cleanse knee with NS (normal saline) and gauze, pat dry and cover with non-adherent dressing.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions related to the wound during showering, or to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 9: The hospice aide care plan dated 07/16/2025 included the following relevant tasks: “bathing (shower), dressing, hair care, may remove oxygen during personal hygiene care, perineal care, shampoo, skin care, stand by assistance with ambulation, observe report changes in condition to RN, will report unusual findings to RN.” Aide visit frequency of twice weekly with all tasks were to be completed every visit unless otherwise specified. A nursing visit dated 08/05/2025 noted “Nursing to cleanse wound with NS and gauze foam dressing to cover. Change twice weekly and PRN (as needed) for dressing failure.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions related to the wound during showering, or to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 11: The hospice aide care plan dated 03/13/2025, updated 03/14/2025 included the following relevant tasks: “turn and position in bed, bathing-bed bath, shampoo, hair care, skin care, will report unusual findings to RN, observe and report changes in condition to RN.” All tasks were to be completed every visit unless otherwise specified. Aide visit frequency of twice weekly. A nursing visit dated 04/10/2025 noted the following “cleanse wound to coccyx with NS and pat dry with gauze. Apply skin prep and barrier cream to peri wound. Apply collagen matrix to wound bed. Cover with bordered dressing. Secure with wound drape.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions related to the wound during showering, or to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 12: The hospice aide care plan dated 02/13/2025 and updated 02/14/2025 included the following relevant tasks: “bathing two times a week (M/F), dressing, hair care, shampoo (M/F), skin care, observe/report changes in condition to RN.” All tasks were to be completed every visit unless otherwise specified. Aide visit frequency of twice weekly. A nursing visit dated 06/30/2025 noted the following: “Remove staples (in head) Monday 07/07/2025.” The hospice aide care plan did not notify the aide of the staples, nor provide specific instructions for hair care related to the head wound during showering or to notify the nurse if the dressing became soiled, dislodged, or wet. CLINICAL RECORD 19: The hospice aide care plan updated 09/18/2024 included the following relevant tasks: “assist to toilet, shower (two times a week), sponge bath (once a week), dressing, hair care, oral care, peri care, shampoo (M, F), skin care, transfer to/from bed/chair, observe/report changes in condition to RN, apply compression stockings. Updated 11/20/2024 to add ear care-hearing aids. All tasks were to be completed every visit unless otherwise specified. Aide visit frequency of three times weekly. A nursing visit dated 09/30/2024 noted the following “left hip, cleanse area with NS and gauze, pat dry, apply collagen to wound bed, cover with silicon dressing.” A nursing visit dated 01/15/2025 noted the following: “Right leg full thickness skin tears. Hospice nurse to cleanse area with NS and gauze, pat dry, apply collagen to wound bed, cover with Mepilex dressing.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions related to the wound during showering, or to notify the nurse if the wound dressing became soiled, dislodged, or wet. A joint clinical record review and interview were conducted with the Director of Nursing on 08/21/2025 in which she responded, “she hadn’t heard about putting the wounds on the care plan before, but it makes sense.””