Harry Hynes Memorial Hospice

“Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview on 09/09/25, it was determined the Hospice failed to provide a copy of its documented risk assessment as required under §418.113(d)(2), Emergency Preparedness – Risk Assessment and Planning. Although the facility had supporting documentation and tools indicating that a risk assessment had been conducted and reviewed by staff, the actual risk assessment could not be produced for review at the time of the survey. Findings Include:Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in January 2025, failed to include a copy of the documented risk assessment as required under §418.113(d)(2). Supporting materials and documentation indicated that the assessment was completed and reviewed; however, the assessment itself could not be located or provided during the survey.During an interview on 09/09/25 between 9:00 AM and 2:00 PM, the Administrator confirmed that the risk assessment had been completed, but the document could not be found or made available for review.”

“Based on policy review, observation, document review, record review, and interview the Hospice failed to ensure the plan of care (POC) included all durable medical equipment (DME) needed for the care of 2 (Patient 2 and 4) of 30 patients sampled. Failure to ensure the POC includes all necessary DME places patients at risk for unmet care needs. Findings Include:Review of the Hospice policy titled, “Plan of Care,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family…”Review of the Hospice policy titled, “Plan of Care – Content,” last reviewed 05/29/24, showed, “The plan of care includes, but is not limited to: … medical supplies, equipment, and appliances necessary to meet the needs of the patient …”Review of the Hospice document titled, “Performance Improvement Project (PIP) Charter Correction of EMR … Compliance Reporting Errors and Clinical Documentation Processes,” last updated 08/25/25 showed, “Scope: This PIP includes EMR [electronic medical record] documentation workflows across all hospice disciplines … it focuses on compliance-sensitive data elements (plan of care, orders, IDG, visit documentation, QAPI events) and related reporting. … Implementation … Completed in July of 2025 … Care planning Education for RN Case Managers … training on constructing symptom-specific, measurable, and interdisciplinary hospice plans of care … Monitoring and Evaluation … Monthly compliance audits … Training effectiveness checks … Manager spot-audits with immediate feedback and coaching … Quarterly QAPI [quality assurance performance improvement] review to adjust protocols and training”. Patient 2Review of Patient 2’s medical record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm (cancer) of the left breast. Review of Patient 2’s POC dated 09/03/25 showed no rollator walker listed under the DME portion of the POC. During a home visit on 09/03/25 at 10:10 AM, Patient 2 was observed using a rollator walker to ambulate from the living room to the bedroom. Patient 4Review of Patient 4’s medical record showed a 95-year-old admitted to hospice services on 12/03/24 with a primary diagnosis of heart failure. Review of Patient 4’s POC dated 09/03/25 showed no rollator walker listed under the DME portion of the POC. During a home visit on 09/09/25 at 1:00 PM, Patient 4 was observed using a rollator walker to ambulate from the bedroom to the bathroom.During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that the POC accuracy was identified as a problem since changing to a new charting system at the end of 2024. Staff G stated that all DME a patient has should be entered on the POC and any additional DME added during care should be updated in the POC. Staff G stated that the new electronic medical record (EMR) has a different process to enter patient owned DME and that this different process has resulted in DME not being recorded in the patient’s POC. Staff G stated that Patient 2 and Patient 4 did not have patient owned DME listed in their POC. Staff G stated that as part of the QAPI program a PIP was created on 08/25/25 identifying a problem with clinical documentation process including the POC accuracy. Staff G stated that any errors identified in any patient’s POC are addressed with the registered nurse (RN) case manager and additional education is provided to reinforce compliance. The Hospice failed to ensure the requirement for activities of daily living (ADLs) was included on the POC for patients that required use of DME.”

“Based on policy review, record review, and interview the Hospice failed to update the plan of care (POC) with new problems, interventions, and goals for 5 (Patient 1, 4, 16, 20, and 26) of 30 patients sampled. Failure to update the plan of care with new problems, goals, and interventions, places patients at risk for unmet care needs and negative outcomes. Findings Include:Review of the Hospice policy titled, “PLAN OF CARE,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive, and updated assessment of the patient. The plan of care is reviewed and updated by the IDG [Interdisciplinary Group] every 15 days or more frequently if the patient’s condition warrants. … Reviews of, and changes to, the plan of care are documented and communicated to members of the IDG.”Review of the Hospice policy titled, “PLAN OF CARE – CONTENT,” last reviewed 05/29/24, showed, “The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. … The plan of care includes, but is not limited to: … interventions to manage pain and symptoms … measurable outcomes anticipated from implementing and coordinating the plan of care …”Patient 1Review of Patient 1’s medical record showed a 73-year-old admitted to hospice services on 01/28/24 with a primary diagnosis of malignant neoplasm (cancer) of the neck.Review of Patient 1’s skilled nursing note on 08/16/25 showed that Patient 1 had an unwitnessed fall and a mattress with bolsters was ordered as an intervention for fall prevention. Review of Patient 1’s interdisciplinary group (IDG) meeting note dated 08/28/25 showed clinical notes made on 08/16/25 when Patient 1 sustained an unwitnessed fall. The note further showed durable medical equipment (DME) of a bolster mattress on 08/16/25 but did not list a fall problem, goal, or intervention. Review of Patient 1’s POC dated 09/03/25 did not show a fall problem, goal, or intervention for the fall that occurred on 08/16/25.Patient 4Review of Patient 4’s medical record showed a 95-year-old admitted to hospice services on 12/03/24 with a primary diagnosis of heart failure.Review of Patient 4’s skilled nursing note on 07/09/25 showed that Patient 4 had a fall on 07/08/25 resulting in a skin tear to the left forearm. The note did not show a fall intervention. Review of Patient 4’s IDG meeting note on 07/09/25 showed a quality assurance performance improvement (QAPI) event of a fall that occurred on 07/08/25. The note did not list a fall problem, goal, or intervention.Review of Patient 4’s POC dated 09/03/25 did not show a fall problem, goal, or intervention for the fall that occurred on 07/08/25. Patient 16Review of Patient 16’s medical record showed an 83-year-old admitted to hospice services on 04/10/25 with a primary diagnosis of malignant neoplasm (cancer) of the kidney. Review of Patient 16’s skilled nursing note on 09/05/25 showed an upper respiratory infection and Azithromycin (antibiotic medication) 250 mg by mouth 2 tabs on day 1, then 1 tab daily for 4 days was ordered.Review of Patient 16’s POC dated 09/10/25 showed no respiratory infection problem, goal, or intervention. Patient 20Review of Patient 20’s medical record showed an 88-year-old admitted to hospice services on 10/05/22 with a primary diagnosis of malignant neoplasm (cancer) of the ovaries. Review of Patient 20’s skilled nursing note on 06/08/25 showed that the patient had a back injury while making the bed and was transported to the hospital for evaluation. Further review of Patient 20’s clinical notes from 06/13/25 showed a diagnosis of a fracture in the patient’s lumbar spine.Review of Patient 20’s IDG meeting note on 06/25/25 showed no spinal fracture problem, goal, or intervention. Review of Patient 20’s POC dated 09/03/25 showed no spinal fracture problem, goal, or intervention. Patient 26Review of Patient 26’s medical record showed a 78-year-old admitted to hospice services on 11/10/23 with a primary diagnosis of senile degeneration of the brain (a state of physical, emotional, and social decline of brain).Review of Patient 26’s skilled nursing note on 02/05/25 showed an oral abscess and Amoxicillin (antibiotic medication) 500 mg by mouth, 1 tab every 8 hours for 7 days was ordered. Review of Patient 26’s IDG meeting note on 02/14/25 showed no oral infection or abscess problem, goal, or intervention. Review of Patient 26’s POC dated 09/03/25 showed no oral infection or abscess problem, goal, or intervention. During an interview on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that the POC for each patient should be updated with any new problems, goals, and interventions. Staff A, stated that the Hospice adopted a new EMR (electronic medical record) within the last year. The new EMR requires input of a coded diagnosis to generate a problem, goals, and interventions to the POC. Staff A, went on to state that instead of inputting individual diagnosis codes for each identified problem (such as the diagnosis code for UTI), staff had been directed to enter everything under the primary diagnosis (such as cancer.) This failure prevented specific problem areas such as wounds, infections, and falls from being identified in the patient’s POC. Staff A, confirmed that a review of patient POCs reflected this concern. During an interview on 09/03/25 at 4:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that a QAPI performance improvement project (PIP) was created in April of 2025 to improve wound documentation and integration of wound care into the POC. Staff G stated that after several months of auditing, integration of information into the POC continued to be problematic. A new PIP was created on 08/25/25 to focus on integrating tracked QAPI events (such as falls, infections, and wounds) into the POC. The Hospice failed to ensure routine updates to the POC.”

“Based on policy review, document review, record review, interview and observation, the Hospice failed to ensure that Registered Nurse (RN) and Home Health Aide (HHA) scheduled visit frequencies were provided as written on the plan of care (POC) for 3 (Patient 13, 17, and 18) of 30 patients sampled. Failure to ensure that POC frequencies are followed as written places patients at risk for unmet care needs. Findings Include:Review of the Hospice policy titled, “Hospice Aide Supervision,” last reviewed 05/29/24, showed, “A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG [interdisciplinary group] and provided by the hospice aide are meeting the patient’s need.”Review of the Hospice policy titled, “PLAN OF CARE,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family … Reviews of, and changes to, the plan of care are documented and communicated to members of the IDG.”Review of the Hospice policy titled, “PLAN OF CARE – CONTENT,” last reviewed 05/29/24, showed, “The plan of care includes, but is not limited to: … a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…”Review of the Hospice policy titled, “COORDINATION OF SERVICES,” last reviewed 05/29/24, showed, “All members of the IDG, volunteers, and contracted personnel have access to the patient’s plan of care and are expected to provide care in accordance with it.”Review of the Hospice document titled, “Performance Improvement Plan: Visit Frequency & Aide Supervisory Documentation Compliance,” created 02/26/25, showed, “Internal audits revealed clinicians were not consistently documenting visit frequencies in the EMR [electronic medical record] … July 2025 and Beyond: Target for full compliance and sustained monitoring through monthly reviews, updated training as needed, and continued recognition of staff performance. … Expected Outcomes … Compliance: 100% adherence to Medicare visit frequency … Accuracy: Elimination of incomplete or missing documentation … Enhanced Patient Care: Improved continuity of services through accurate scheduling …”Patient 13Review of Patient 13’s medical record showed an 84-year-old admitted to hospice services on 05/19/25 with a primary diagnosis of malignant neoplasm (cancer) of the left breast.Review of Patient 13’s POC dated 09/03/25 showed an HHA visit frequency of two times weekly.Review of Patient 13’s IDG meeting note dated 08/29/25 showed an HHA visit frequency of two times weekly. Review of Patient 13’s record from 06/01/25 - 06/07/25 showed only one HHA visit was completed on 06/03/25. The record failed to show documented evidence that a second weekly visit was completed as required.Patient 17Review of Patient 17’s medical record showed a 91-year-old male admitted to hospice services on 06/19/24 with a primary diagnosis of malignant neoplasm (cancer) of the ascending colon.Review of Patient 17’s POC dated 09/03/25 showed a skilled nursing visit frequency of one time weekly and six PRN (as needed) visits. Review of Patient 17’s IDG meeting note dated 07/09/25 showed a skilled nursing visit frequency of one time weekly and six PRN visits. Review of Patient 17’s clinical notes for skilled nursing showed an RN visit completed on 06/20/25 and a subsequent RN visit completed on 07/11/25. Further review failed to show documented evidence of weekly skilled nursing visit for the week of 06/22/25 and 06/29/25 as required. Patient 18Review of Patient 18’s medical record showed an 88-year-old admitted to hospice services on 02/25/25 with a primary diagnosis of senile degeneration of the brain (a state of physical, emotional, and social decline of brain)Review of Patient 18’s POC dated 09/03/25 showed an HHA visit frequency of one time weekly. Review of Patient 18’s IDG meeting note dated 07/18/25 showed an HHA visit frequency of one time weekly. Review of Patient 18’s clinical notes for the HHA showed a visit made on 07/16/25 and a subsequent HHA visit made on 07/31/25. Further review failed to show documented evidence of a HHA visit for week of 07/20/25. During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management stated that visit frequency and scheduling for clinical staff was identified as problem since changing to a new charting system at the end of 2024. During an interview on 09/10/25 at 4:05 PM Staff A, Vice President of Clinical Services, stated that visit frequencies should be followed as written on the POC. Staff A confirmed that review of Patient 13’s medical record failed to show evidence of a second HHA visit for the week of 06/01/25 and no missed visit note. Staff A confirmed that review of Patient 17’s medical record failed to show evidence of skilled nursing visit notes for the week of 06/22/25 and the week of 06/29/25. Staff A stated that Staff M, RN Case Manager, was on vacation during those 2 weeks and communication of visit coverage for Patient 17’s skilled nursing visits was missed. Staff A confirmed that review of Patient 18’s medical record failed to show an HHA visit for the week of 07/20/25 and no missed visit note. The Hospice failed to ensure that all visit frequencies listed on the POC were accounted for and fulfilled.”

“Based on policy review, record review, and interview, the Hospice failed to communicate medication changes with non-hospice caregivers for 1 (Patient 2) of 30 patients sampled. Failure to provide an accurate medication list with non-hospice caregivers places these patients at risk for unmanaged symptoms and negative outcomes. Findings Include:Review of the Hospice policy titled, “COORDINATION OF SERVICES,” last reviewed 05/29/24, showed, “An assigned hospice RN coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.”Patient 2Review of Patient 2’s record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm of the left breast.Review of Patient 2’s medications showed the following:1. Review of Patient 2’s plan of care (POC) medication list and “Patient Medication List” dated 09/03/25 showed that Miralax (laxative medication) was to be administered once every day.Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed that the medication was only to be administered daily AS NEEDED. 2. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Levsin (medication used to reduce oral secretions) was to be administered in a quantity of one tablet every six hours as needed. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed the medication was to be administered in a quantity of two tablets every six hours as needed. 3. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Miebo ophthalmic solution (medication for dry eyes) was to be administered three times daily. Review of Patient 2’s residing facility’s medication record dated 09/03/25 did not list Miebo ophthalmic solution.4. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Refresh Optive ophthalmic gel (medication for dry eyes) was to be administered two times daily. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed the medication was to be administered three times daily. 5. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed Fiber-Lax (laxative medication) tablet to be administered daily. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 failed to show Fiber-Lax tablet. 6. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed Montelukast Sodium (medication to treat allergies) to be administered one time daily. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 failed to show Montelukast Sodium 10mg tablet. During an interview with on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that each patient medication list is entered at the time of admission, reviewed by the medical director and pharmacy, and updated with any changes and during interdisciplinary group (IDG) every 2 weeks. Staff A stated that the registered nurse case manager (RNCM) is responsible for communicating and updating any changes to the patient POC or medication list.”

“Based on policy review, observation, and interview the Hospice failed to ensure standard practices of infection control were followed. Failure to follow appropriate infection control practices places patients at risk for exposure to communicable diseases and infections. Findings Include:Review of the Hospice policy titled, “INFECTION CONTROL – PROGRAM,” last reviewed on 05/29/24, showed, “…maintains and documents an effective, organization-wide infection control program that includes active monitoring, surveillance, identification, prevention, and control … The hospice’s infection control program includes, but is not limited to the following components: … education and training for staff … a written bloodborne pathogen exposure control plan”.Review of the Hospice policy titled, “INFECTION CONTROL - BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN,” last reviewed on 05/29/24, showed, “A written Bloodborne Exposure Control Plan (ECP) is maintained in accordance with OSHA standard 29 CFR 1910.1030 to prevent and control diseases caused by bloodborne pathogens or other potentially infectious materials. … Methods of compliance: … proper clean up and decontamination practices and handling regulated waste.”Review of the Hospice policy titled, “INFECTION CONTROL - STANDARD AND TRANSMISSION - BASED PRECAUTIONS,” last reviewed 05/29/24, showed, “Hospice staff are required to use standard precautions in the care of all hospice patients … Standard precautions include, but are not limited to: … Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Centers for Disease Control and Prevention (CDC) standards. A tour of Location 3 (L3) on 09/04/25 at 1:55 PM showed a biohazard waste (potentially infectious materials that could pose a threat to public health or the environment) receptacle was stored between shelves of supplies in the clean supply room. The biohazard receptacle was open without a lid. During an interview on 09/04/25 at 1:55 PM, Staff E, Vice President of Clinical Services, stated that the biohazard receptacle is used for disposal of biohazard materials and is picked up by a contracted company one time a month.Patient 17 Review of Patient 17’s medical record showed a 91-year-old male admitted to hospice services on 06/19/24 with a primary diagnosis of malignant neoplasm (cancer) of the ascending colon.During a home visit for Patient 17 on 09/09/25 at 11:00 AM, Staff M, Registered Nurse Case Manager (RNCM), was observed using a blood pressure cuff on Patient 17. After use, Staff M failed to disinfect the cuff and placed it back into its storage container and then into his/her bag of clean equipment and supplies. During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that the expectation for clinical staff is to follow nationally recognized infection control practices. Staff G, stated all staff receive initial orientation and annual education for all clinical standards of practice including infection control.The Hospice failed to ensure appropriate infection control practices were maintained placing patients at risk for transmission of infections.”

“Based on policy review, record review, and interview the Hospice failed to ensure a registered nurse (RN) performed a home health aide (HHA) supervisory visit at least every 14 days for 3 (Patient 1, 2, and 8) of 30 patients sampled. Failure to ensure an HHA supervisory visit is performed every 14 days places patients at risk for unmet care needs. Findings Include:Review of the Hospice policy titled, “HOSPICE AIDE SUPERVISION,” last reviewed 05/29/24 showed, “Hospice aides are supervised by a registered nurse in a manner and frequency that assures the safety of patients and the quality of aide services provided. … A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need. … The supervisory visits are documented in the patient’s clinical record every two weeks and include notation regarding the aide’s competency, whether the aide is following the patient’s plan of care, and is satisfactory to the patient/family.”Patient 1Review of Patient 1’s record showed a 73-year-old admitted to hospice services on 01/28/24 with a primary diagnosis of malignant neoplasm (cancer) of the neck. Review of Patient 1’s RN supervisory notes showed an RN supervisory visit performed on 06/09/25 and a subsequent RN supervisory visit performed 07/01/25 for a gap of 22 days between supervisory visits for the HHA.Patient 2Review of Patient 2’s record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm of the left breast. Review of Patient 2’s RN supervisory notes showed an RN supervisory visit performed on 05/13/25 and a subsequent RN supervisory visit performed 05/28/25 for a gap of 15 days between supervisory visits for the HHA.Patient 8Review of Patient 8’s record showed a 83-year-old admitted to hospice services on 04/25/25 with a primary diagnosis of Alzheimer’s disease (a progressive disease, causing decline in memory loss and mental function). Review of Patient 8’s clinical notes showed an RN admission note performed on 04/25/25 establishing initial patient HHA frequency of 2 times weekly. The first RN supervisory visit was performed on 05/23/25 a gap of 28 days without an RN supervisory visit for the HHA. During an interview on 09/10/25 at 4:05 PM Staff A, Vice President of Clinical Services, stated that RN supervisory visits of an HHA should occur at least every 14 days. Staff A stated that review of Patient 1’s medical record failed to show an RN supervisory visit from 06/09/25 to 07/01/25. Staff A stated that review of Patient 2’s medical record failed to show an RN supervisory visit from 05/13/25 to 05/28/25. Staff A stated that review of Patient 8’s medical record failed to show an RN supervisory visit from 04/25/25 to 05/23/25. The Hospice failed to ensure RN supervisory visits were performed to oversee HHA’s at least every 14 days.”

“Based on policy review, observation, document review, contract review, and interview the Hospice failed to ensure a sanitary environment was maintained on the in-patient unit (IPU). Failure to maintain a sanitary environment places all patients in the IPU at risk for infection or communicable diseases. Findings Include: Review of the Hospice policy titled, “INFECTION CONTROL – PROGRAM,” last reviewed on 05/29/24 showed, “…maintains and documents an effective, organization-wide infection control program that includes active monitoring, surveillance, identification, prevention, and control …”Review of the Hospice policy titled, “INFECTION CONTROL – BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN,” last reviewed on 05/29/24, showed, “A written Bloodborne Exposure Control Plan (ECP) is maintained in accordance with OSHA standard 29 CFR 1910.1030 to prevent and control diseases caused by bloodborne pathogens or other potentially infectious materials. … Methods of compliance: … proper clean up and decontamination practices and handling regulated waste.”Review of the Hospice policy titled, “INFECTION CONTROL - STANDARD AND TRANSMISSION - BASED PRECAUTIONS,” last reviewed 05/29/24, showed, “Hospice staff are required to use standard precautions in the care of all hospice patients … Standard precautions include, but are not limited to: … Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Centers for Disease Control and Prevention (CDC) standards.”Review of the Hospice document titled, “Work Order,” dated 09/03/25, showed a second request for a repair of the sink in the dirty utility room with an additional comment on 09/02/25 a technician noted “I plunged sink several times without success.”Review of the Hospice lease contract with the hospital for the IPU dated 07/12/04 showed, “Landlord shall keep the Premises, and all the equipment located therein (except equipment provided by Tenant) in good order, condition and repair, and in compliance with all applicable federal, state, and local laws and regulations.” A tour of the IPU on 09/03/25 at 8:40 AM showed a clogged sink located in the dirty utility room with approximately 4 inches of dirty foul-smelling water. During a revisit of the IPU on 09/05/25 at 2:15 PM the clogged sink in the dirty utility room had been taped off with blue masking tape that read, “Do Not Use.” The standing water remained in the sink. During an interview on 09/03/25 at 9:00 AM, Staff C, Support Services Coordinator, confirmed the presence of standing water in the sink located in the dirty utility room on the IPU and stated that the sink was not draining properly. During an interview on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that the sink located in the dirty utility room on the IPU was not working properly. The Hospice failed to maintain a sanitary environment on the IPU due to failure to drain, clean, and repair of a sink in the dirty utility room that had standing dirty water from 09/02/25 through 09/05/25.”

“Based on interviews, record review, and policy review, the facility failed to report an allegation of abuse to the state agency that involved 1 (Patient 1) of 4 sampled patients reviewed for abuse. Findings included: Review of a facility policy titled, “;Assessment of Possible Abuse/Neglect,” revised October 2019, revealed, “;The organization will report all suspected cases of abuse, neglect, or exploitation, in compliance with applicable state statutes to appropriate protection organizations.” A review of undated state statute titled, “;Adult Mandatory Reporters 39-1431,” revealed “;Abuse, neglect or exploitation of certain adults; reporting abuse, neglect or exploitation or need of protective services; persons required to report; penalty of failure to report, posting notice of requirements of act. (a) Any person who is licensed to practice any branch of the healing arts, a licensed psychologist, a licensed master level psychologist, a licensed clinical psychotherapist, the chief administrative officer of a medical care facility, a teacher, a licensed social worker, a licensed professional nurse, a licensed practical nurse, a licensed dentist, a licensed marriage and family therapist, a licensed clinical marriage and family therapist, licensed professional counselor, licensed clinical professional counselor, registered alcohol and drug abuse counselor, a law enforcement officer, a case manager, a rehabilitation counselor, a bank trust officer or any other officers of financial institutions, a legal representative, a governmental assistance provider, an owner or operator of a residential care facility, and independent living counselor and the chief administrative officer of a licensed home health agency, the chief administrative officer of an adult family home and the chief administrative officer of a provider of community services and affiliates thereof operated or funded by the department for children and families or licensed under K.S.A. 75-3307b and amendments thereto who has reasonable cause to believe that an adult is being or has been abused, neglected or exploited or is in need of protective services shall report, immediately from receipt of the information, such information or cause a report of such information to be made in any reasonable manner. An employee of a domestic violence center shall not be required to report information or cause a report of information to be made under this subsection. Other state agencies receiving reports that are to be referred to the department for children and families and the appropriate law enforcement agency, shall submit the reports to the department and agency within six hours, during normal workdays, of receiving the information. Reports shall be made to the department for children and families during the normal working weekdays and hours of operation. Reporters shall be made to law enforcement agencies during the time social and rehabilitation services are not in operation. Law enforcement shall submit the report and appropriate information to the department for children and families on the first working day that department for children and families is in operation after receipt of such information.” A review of Patient 1s “;Combined Discipline Comprehensive Assessment,” dated 10/26/23, revealed the facility admitted Patient 1 on 03/07/19, with diagnoses that included neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), Parkinsons disease, and heart failure. A review of Patient 1s “;Nurse Progress Note Routine Visit,” dated 10/30/23 and electronically signed by Registered Nurse Case Manager (RNCM) 3, revealed Paid Caregiver (PCG) 1 reported after she viewed home camera videos related to how Patient 1 sustained a skin tear to the right hand while being cared for by a nightshift caregiver, who no longer was employed by the facility due to patient abuse. Per the Nurse Progress Note Routine Visit, PCG 1 verbalized the paid caregiver hit, taunted, and mocked the patient when the patient cried. Per the Nurse Progress Note Routine Visit, PCG 1 reported the caregiver laid the patient in bed and fed the patient a dark colored liquid by wat of a syringe which caused the patient to cough, choke, and become short of breath. The Nurse Progress Note Routine Visit indicated the caregiver laughed, mocked, and turned the television volume up louder. The Nurse Progress Note Routine Visit revealed the office manager, social worker, and physician were notified of the reported abuse. A review of Patient 1s “;Interdisciplinary Note,” dated 10/30/23, electronically signed by Licensed Medical Social Worker (LMSW) 4, revealed the social worker placed a phone to Patient 1s residence to follow up regarding the alleged abuse of the patient by another paid caregiver. During an interview on 11/09/23 at 2:58 PM, PCG 1 stated that on 10/27/23 another PCG who was not affiliated with the agency (PCG 2) contacted her and reported Patient 1 had sustained an injury to their right hand. PCG 1 stated she notified RNCM 3 of the injury. According to PCG 1, RNCM 3 visited the Patient 1, assessed and treated the injury on Patient 1s right hand, and suggested they watch the video of the 10/26/23 overnight shift due to the appearance of the skin on Patient 1s hand. PCG 1 stated while watching the video, she observed and heard Patient 1 loudly cry out while PCG 2 grabbed and pulled on Patient 1s hand. Per PCG 1, PCG 2 leaned over Patient 1 and used “;a mocking tone” said “;go ahead and cry some more.” PCG 1 stated, Patient 1 shouted “;my hand,” and PCG 2 left Patient 1 alone in the room to cry. According to PCG 1, on the video, PCG 2 returned with a syringe filled with an unknown dark liquid and administered the fluid orally to Patient 1, who began to gasp and make. PCG 1 stated on 10/30/23 or 10/31/23 she told RNCM 3 what she had observed on the video and RNCM 3 told PCG 1 she would discuss this information with LMSW 4. On the afternoon of 10/30/23 or 10/31/23, PCG 1 stated she spoke with LMSW 4 and described what she observed on the 10/26/23 overnight shift video, and her concerns that PCG 2 had abused Patient 1. PCG 1 stated LMSW 4 texted her information on how to report allegations to Adult Protective Services (APS). During an interview on 11/10/23 at 12:50 PM, RNCM 3 stated that PCG 1 reported Patient 1 had a skin tear that occurred during an overnight shift. According to RNCM 3. PCG 1 later reported she watched the video from the overnight shift of 10/26/23 and observed another PCG abuse Patient 1. RNCM 3 stated PCG 1 asked how to report the alleged abuse and RNCM 3 provided instruction on who to contact. RNCM 3 stated she then notified the Vice President of Clinical Services (VPCS), LMSW 4 and the patients physician. RNCM 3 stated she did not report the abuse allegation to any state agencies because it was “;hearsay,” she did not have proof of the abuse happening. RNCM 3 stated the agency policy was the nurse reported allegations of abuse to the clinical supervisor and notified an agency social worker who would then contact Adult Protective Services (APS). During an interview on 11/10/23 at 1:15 PM, LMSW 4 stated that on 10/30/23, RNCM 3 told her that PCG 1 had shared an allegation that PCG 2 injured Patient 1s hand. LMSW 4 stated she provided education to PCG 1 on how to report an allegation of abuse to APS. LMSW 4 stated she did not report the abuse allegation to any state agencies as she had no suspicions that abuse had occurred, she did not see any proof that abuse happened, and considered the allegation “;hearsay.” LMSW 4 defined an allegation of abuse as when she witnessed the event or believed that abuse had happened. During an interview on 11/13/23 at 9:45 AM, the VPCS stated that on 10/30/23, PCG 1 reported she viewed the video of Patient 1s care and reported the overnight PCG abused Patient 1. Per the VPCS, the facility did not report the allegation of abuse to APS because the patients family had already reported the incident.”