Canyon Home Care & 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; other alternative treatments that could affect drug therapy. This standard was not met, as evidenced by clinical record review and interview. In 1 of 4 (25%) 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 4: The patient elected the hospice benefit on 11/24/2025 for a diagnosis of Parkinson’s disease. The patient resided in an adult certified home (AH). During Home Visit 4 with Personnel Record 5 (Social Worker) on 02/18/2026, the hospice medication profile (printed on 02/17/2026) was compared to the AH medication profile. The following medications were listed on the hospice list and not on the AH list: “Bisacodyl 10 mg suppository. 1 daily as needed (ordered 11/24/2025); Fleet enema. 1 daily as needed, to be given after Bisacodyl (ordered 11/25/2025); Atropine 0.1 mg/ml. Every 8 hours as needed (ordered 12/05/2025); Haloperidol 2mg/ml. Every 6 hours as needed (ordered 12/05/2025).” The following discrepancy was noted: hospice had Senna S 50 mg/8.6 mg, take 1 tablet once daily (ordered 12/02/2025) vs AH had Senna S 50 mg/8.6 mg, take 1 tablet twice daily (ordered 02/12/2026). A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/20/2026. The Hospice Program Director “wanted to know how they were supposed to make sure facilities wrote all the medications in their lists if they faxed the orders over to them?” She said, “ Sometimes it seems hard to get them to keep their lists updated.””

“It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment and per the plan of care. This standard was not met, as evidenced by clinical record review, and interview. In 5 of 19 (26%) clinical records reviewed revealed that social work services ordered on the Plan of Care (POC) did not follow the POC as ordered and based on the patient’s or family’s acceptance of these services. CLINICAL RECORD 4: The initial social work assessment dated 11/24/2025 and plan of care (POC) noted the following: “The family has not decided on a funeral home yet. The MSW (medical social worker) will follow up with the family about this. Recently moved from an ALF (assisted living facility) to a certified family home for a higher level of care. Frequency to be once monthly.” A missed visit note dated 12/23/2025 documented “At this time, there are no known needs or concerns for this patient. MSW will continue to follow and intervene as needed.” On 01/23/2026, the visit was marked as a missed visit without a note to document a reason. The interdisciplinary group notes/Plan of Care updates from the social worker reflected the same information as the initial assessment or missed visit notes. CLINICAL RECORD 8: The initial social work assessment dated 08/11/2025 and plan of care (POC) noted the following: “Assess bereavement needs of the caregiver, family, and other individuals that may impact their ability to cope with the patient’s death. Frequency to be twice monthly visits.” Visit was made on 08/20/2025. A note dated 08/29/2025 noted the following: “Patient had too many visits scheduled for the day. Will use PRN (as needed) next week if no visit plotted.” There was not a follow up note or visit documented. A visit was documented on 09/17/2025. A note was documented for a missed visit on 09/30/2025 due to “scheduling conflict.” A missed visit was documented for 10/16/2025 with a note that stated: “No known immediate needs or concerns at this time. MSW will continue contact with RNCM for any emergent needs.” A visit was attempted on 10/30/2025 with a note: “Patient was napping, and MSW didn’t want to disturb her.” A Plan of Care Order dated 11/12/2025 to 1/31/2026 changed the visit frequency to once monthly. A note for a missed social work visit on 11/30/2025 documented: “Patient has no known needs or concerns at this time. Visit will be missed due to holiday hours.” A noted document on 12/30/2025 noted a social work missed visit “EOM/year. Unable to reschedule. Will utilize PRN visit if needed.” There was no documented social work IDG note for the IDG dated 11/20/2025, although the social worker was present at IDG per the sign-in sheet. The social work interdisciplinary (IDG) note for 12/18/2025 documented: “No visit this IDT period.” The IDG note on 12/31/2025 noted: “Patient has not been seen this IDT period.” CLINICAL RECORD 10: The initial social work assessment dated 10/10/2025 and plan of care (POC) noted the following: “Frequency once a month in October, then twice a month for the rest of certification.” A note for a missed visit dated 11/28/2025 stated: “Patient has no known needs or concerns at this time. Visit will be missed due to holiday hours and inability to move due to the end of the month.” 12/17/2025, it was noted: “Phone call made.” 12/30/2025, it was noted “Unable to reschedule visit due to EOM/end of year. PRN visit will be added if needed before the next scheduled visit.” The interdisciplinary meeting notes and POC update dated 12/18/2025 noted: “Phone call with ***********. Discussed holiday and plans.” The IDG note and POC update dated 12/30/2025 noted: “Patient has not been seen this IDT period.” CLINICAL RECORD 14: The initial social work assessment dated 11/12/2025 and plan of care (POC) noted the following: “Visit frequency of once a month in November, then twice a month for the rest of the certification.” The clinical record review revealed phone calls documented on 11/26/2025 and 12/17/2025. A missed visit was documented on 12/23/2025, which listed “No known needs or concerns for the patient at this time. MSW will continue to follow and intervene as needed.” A missed visit was documented on 01/31/2026 with the reason listed as “Schedule conflicts.” The IDG notes and POC updates listed “Patient not seen during cert period and no needs or concerns at this time.” CLINICAL RECORD 19: The initial social work assessment dated 09/01/2025 and plan of care (POC) noted the following: “Social work visit frequency of once monthly for emotional support and assessment of needs.” A missed visit note dated 09/30/2025 listed “scheduling conflicts” as the reason for the missed visit. A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/19/2025, during which time the social worker’s missed visits were discussed and the lack of plan of care updates. It was discussed that missed visits “should only be at the patient or family/caregiver request, not scheduling conflict, holiday hours and that visits should not wait until the end of the month to be scheduled if the patient/family has accepted the social worker services.” There should be plan of care updates for each IDT by every discipline that are relevant and “these cannot be accomplished with all visits being missed.” A new social worker has been hired to help provide services as requested by patients/families.”

“It is required that written patient care instructions for a hospice aide are prepared by an 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 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 5: The hospice aide care plan dated 10/13/2025 thru 01/07/2026 included the following tasks: “Hygiene: Bath: bed; Bath: shower; Bath: shower chair; Nail care: may clean and/or file; Nail care; Companionship (added 10/28/2025); Skin care; Home management: clean bathroom after use; Hygiene: oral care; Hygiene: shampoo; Elimination: Report to RN if no BM (bowel movement in 3 days; Incontinent care.” All tasks were to be completed every visit with an aide frequency of twice weekly. The aide care plan did not provide the aide(s) with specific instructions for which type of bath to provide for the patient during the visit(s). CLINICAL RECORD 17: The hospice aide care plan 09/06/2025 included the following tasks: “Assist to BSC (bedside commode)/toilet; assist with dressing; shampoo; perineal care; skin care; make patient bed; oxygen precautions; change adult diapers, bathing-bed bath; bathing-shower; assist with transfers; clean bathroom after care; change linen; incontinence care; oral care. All tasks were to be completed every visit with an aide frequency of twice weekly. The aide care plan did not provide the aide(s) with specific instructions for which type of bath to provide for the patient during the visit(s). A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/19/2025, during which time it was agreed that the “nurses who entered the care plan should have only put one bath type with specific instructions for the aides.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met, as evidenced by document review and interview. A review of the volunteer program was conducted with the Hospice Program Manager, Administrator, and Clinical Managers on 02/19/2026, during which time the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged to 4.0%. The Volunteer Coordinator was off during the interview, and the information was provided by the Regional Volunteer Manager. The Volunteer Coordinator was given that role in October 2025 and, per the Hospice Program Manager, is “still being provided training for the role.” During the interview, the Hospice Program Manager advised, “We are staffed well with volunteers; however still having difficulty getting patients/families to accept them into the homes and obtain the required hours. We will continue to increase our administrative hours in the meantime.” A review of the volunteer program was conducted with the Hospice Program Manager, Administrator and Clinical Managers on 02/19/2026, during which time the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged to 4.0%. The Volunteer Coordinator was off during the interview and the information was provided by the Regional Volunteer Manager. The Volunteer Coordinator was given that role in October 2025 and and per the Hospice Program Manager is “still being provided training to the role.” During the interview, the Hospice Program Manager advised “We are staffed well with volunteers however still having difficulty getting patients/families to accept them into the homes and obtain the required hours. We will continue to increase our administrative hours in the meantime.””

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included a completed initial bereavement assessment. Clinical Record 2: The patient elected the hospice benefit on 06/20/2024. The record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the comprehensive assessment included a completed initial bereavement assessment.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 1 of 3 (33%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included goal(s) and intervention(s) based on problems identified in the initial comprehensive assessments. Clinical Record 1: The initial nursing assessment dated 09/13/2023 reported “Emotional Status: Patient agitated.” The RN’s narrative also stated, “She is agitated, very fidgety, not sitting still well.” The POC dated 09/13/2023 lacked evidence of goal(s) and intervention(s) for agitation. The nursing assessment reported “Status: Genitourinary: Incontinent.” The POC dated 09/13/2023, lacked evidence of goal(s) and intervention(s) for urinary incontinence. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the POC included goal(s) and intervention(s) based on problems identified in the initial comprehensive assessments.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the aide reported changes in the patient’s medical needs to the registered nurse (RN) as the changes related to the aide care plan. Clinical Record 3: The aide care plan dated 06/30/2024 ordered the tasks “Elimination: Incontinent Care”, “Home Management: Change patient linen” and “Hygiene: Oral Care”. The aide visit note dated 07/09/2024 reported “Patient refused” for the ordered tasks: “Elimination: Incontinent Care”, “Home Management: Change patient linen” and “Hygiene: Oral Care”. The record lacked evidence that the aide notified the RN of the changes in the patient’s medical needs as related to the aide care plan. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the hospice aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan.”