Unitypoint Hospice

“Based on document review and staff interviews, for 1 of 2 (Pt #2) patient’s requiring durable medical equipment. the facility failed to coordinate and provide durable medical equipment in accordance with patient and family needs. 1. Pt #2’s record was reviewed. Pt #2 was admitted on 3/22/26 with a diagnosis of “Frontal mass of the brain.” Pt #2’s record included an order for a Hoyer lift on 5/1/2026. Pt #2’s record lacked documentation that Pt #2 received the Hoyer lift. 2. Review of the facilities policy titled Home Medical Equipment and Supplies (Effective 11/2026), indicated “4. “The Registered Nurse (RN) requests the ordered home medical equipment (HME) from the provider and informs the patient/caregiver of its expected delivery time and ensures that the patient/caregiver receives adequate instruction and information related to the equipment used by the patient through demonstration and teach back. The HME providers also provide education and instruction to the patient and caregiver.”3. An interview was conducted with the Hospice Administrator (E# 3). E #3 reviewed Pt #2’s record and verbally agreed that there is no documentation that Pt #2 received the Hoyer lift as prescribed. E #3 stated, “We do not have a process to track when patients receive their DME.””

“Upon patient record review, 3 of 19 (Patient #3,#4,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3:The medication profile includes entries for Calcium Polycarbophil fiber laxative as needed for constipation and oxygen inhale 2 liters per minute into lungs for shortness of breath. There is no evidence that the entry includes the type and amount of diluent for administration of the laxative or a route for administration of the oxygen. Patient 4:The medication profile includes entries for Benadryl ointment and a lidocaine patch. There is no evidence that the entries include a location for administration. Patient 10:The medication profile includes an order for gentamycin cream and there is no evidence that the entry includes the location for administration. The plan of care includes an order for oxygen 2-5 liters per minute via nasal cannula for shortness of breath. There is no evidence that the medication profile includes an entry for oxygen.”

“Upon patient record review, 4 of 19 (Patient #6,#8,#10,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6:The medical record included nursing documentation of a chronic wound to the right eye and diagnoses of CHF, cardiomyopathy, aortic valve stenosis, right bundle branch block, and pacemaker. There is no evidence that the plan of care includes problems, goals and interventions for wound management and cardiac. Patient 8:The medical record includes documentation that the patient has a primary diagnosis of late effects CVA, with comorbidities of occlusion of left, middle and right cerebral artery and right carotid with hypertension, blood clotting disorder and history of thrombosis and embolism and is at risk for aspiration due to enteral feeds via gastrostomy tube. There is no evidence that the plan of care includes problems, goals and interventions for the management of neuro and cardiac disease and the risk for aspiration. Patient 10:The medical record includes documentation the patient has a primary diagnosis of hypertensive heart disease with heart failure and is on fluid restrictions of 2500 cc/day. There is no evidence that the plan of care includes problems, goal and interventions to manage cardiovascular disease or a fluid restricted diet. Patient 13:The medical record includes documentation that the patient is currently receiving Macrobid for an active infection, has ongoing symptoms of nausea and vomiting that is being managed with medication, has a colostomy and has a primary diagnosis of colorectal cancer. There is no evidence that the plan of care includes problems, goals and interventions to manage an active infection, gastrointestinal symptoms, colostomy care and the primary diagnosis of cancer.”

“Upon patient record review, 2 of 19 (Patient #6,#12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 6:The medical record includes documentation that the patient experienced a fall from slipping out of a wheelchair. There is no evidence that the plan of care includes a wheelchair. Patient 12:Upon observation during the home visit, the patient requires a hospital bed and a sit to stand lift. There is no evidence that the plan of care includes these equipment needs.”

“Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 9:The plan of care notes that patient is at high risk for falls. The aide plan of care does not include fall precautions.”