Home Town Hospice

“Based on record review, observation and interview, the hospice failed to ensure medications from the Skilled Nursing Facility (SNF) matched the medications that the hospice had ordered for 1 (Patient 3) of 13 sampled patients. This deficient practice has the potential to affect the accuracy and safety of medications ordered for patients. Findings Include: Review of an agency record titled, “Patient Face Sheet,” showed that the patient was admitted to hospice on 10/23/24 with a diagnosis of chronic diastolic (congestive) heart failure (a stiff left heart ventricle that prevents the heart from relaxing between beats.) During a home visit observation on 01/09/25 at 11:00 AM at the SNF, Patient 3’s facility medications were confirmed to the surveyor by the Registered Nurse at the SNF. The following medications were not listed on the list of medications at the SNF, however were ordered on the list provided by the Hospice Agency:1. Menthol (a topical pain medication) 6% topical pad 6% film. Apply one film(s) applied topically one to two times a day as needed for moderate pain; apply one film per location (knees, back), 2) Melatonin (a sleep medication) 3 milligrams (mg) oral tablet, disintegrating; Take one to two tablets orally once a day (at bedtime) as needed for insomnia, 3) MiraLAX (a laxative)– oral powder for reconstitution; Administer 17 grams orally once a day as needed for constipation, 4) Multiple Vitamin (a vitamin) oral tablet; Take 1 tablet orally once a day, 5) NyQuil (a cough medication) Cold/Flu Relief 1000 mg-30 mg-12/5 mg/30 ml (milliliter) oral liquid; Take 30 ml orally every six hours as needed for cough, and 6) Tylenol (pain medication) 8 hour Arthritis Pain, 650 mg oral tablet; extended release; Take one to two tablets orally every eight to 12 hours as needed for mild pain; do not exceed 3 grams Tylenol daily. The same home visit observation showed Staff B, Registered Nurse (RN) did not reconcile (compare and review) the hospice medications to the SNF medications with the SNF nursing staff. During an interview on 01/09/25 at 4:05 PM, Staff C, Registered Nurse (RN) stated, “I try to talk to the RN when I go to the nursing home, but I don’t check the patient’s medications each time.” During an interview on 01/10/25 at 2:05 PM, Staff B, Director of Patient Services (DPS) stated, “Every visit the nurse is to check the patient’s medications and make sure it matches to what we have on our medication list.” Staff B confirmed the list of medications at the SNF did not match the list of medications the hospice had listed and confirmed the patient was ordered to have the medications and should have been given the medications.”

“Based on policy review, record review, and interviews, the hospice failed to ensure the patient and caregiver received education and training provided by the hospice, for medication disposal according to the plan of care for 1 (Patient 10) of 9 patients reviewed. Failure to ensure that each patient and caregiver receive appropriate instructions related to plan of care responsibilities that included medication disposal, places patients, caregivers and staff at risk for medication exposure and potential negative outcomes from unsafe medication disposal. Findings Include: Review of hospice policy titled, “Dispensing and Administration of Medications and Controlled Substance,” dated 02/22/24, showed, “...Hospice nursing staff shall recommend and educate on the disposal of all non-controlled and controlled substances no longer needed by the patient...” Review of Patient 10’s record titled, “Patient Face Sheet,” showed, Patient10 was admitted to hospice services on 03/25/24 with the diagnosis of neurocognitive disorder with Lewy bodies (progressive brain disorder,) dementia, and chronic pain syndrome. Review of Patient 10’s record titled, “Physician Orders,” showed an order on the plan of care, dated 06/21/24, for “;Fentanyl25 MCG/HR (micrograms per hour) patch. Apply one patch transdermally every 72 hours for severe pain.” Review of Patient 10s record titled, “RN [Registered Nurse] Routine Visit,” dated 06/25/24, showed Patient 10 removed the Fentanyl patch every 72 hours. There was no documentation to support the nurse educated and trained the patient or caregiver on the proper way to dispose of the Fentanyl patch. Further review of records titled, “;RN Routine Visit,” for the dates of July through December of 2024, showed no documentation to support Patient 10, nor caregiver, were educated and trained on the appropriate removal and disposal of the Fentanyl patch each 72 hours as required. During an interview on 01/09/25 at 3:00 PM, Caregiver (C)1, was asked if the nurse had provided C1 with education on how to dispose of the Fentanyl patches. C1 replied, “No, they didn’t tell me anything about it. I have just been wearing gloves to remove the patch then putting the patch I take off inside the glove and put it in the trash.” During an interview on 01/09/25 at 4:00 PM, Staff C, Registered Nurse (RN), was asked if any education was provided to Patient 10 or the caregiver on proper disposal of Fentanyl patches when they were removed. Staff C stated, “I don’t remember if I did or not.” During an interview on 01/10/25 at 2:55 PM, Staff B, Director of Patient Services (DPS), stated, “Any education that the nurse gives to the patient, or the caregiver should be documented.””

“Based on policy review, document review, observation, and interviews, the hospice failed to implement accepted standards of practice to prevent the potential of transmission of infections and communicable diseases for 2 (Patients 3 and Patient 10) of 3 patients with home visits and for 1 (Staff E) of 5 staff members. This deficient practice has the potential to affect proper infection control practices in the home for all patients who receive hospice services and staff providing those services. Findings Include: Review of hospice policy titled, “Tuberculosis Screening Program (TB),” revised 08/05/22, showed, “To prevent the transmission of tuberculosis within the organization and the community through an effective proactive screening program. It is the policy of [name of the hospice agency] to screen all employees for the presence of inactive or active Tuberculosis at the time of employment and at least annually thereafter...Employees must also have a two-step TB skin test, which must be completed within 30 days after hire.” Review of hospice policies showed the hospice failed to provide a policy as requested for Hepatitis B. Review of hospice policy titled; “Cleaning of Reusable Equipment” dated 08/24 showed “... All reusable patient care equipment and surfaces must be cleaned immediately after use, even if not visibly soiled... Gloves must be used for the cleaning process...” Patient 3 During a home visit observation on 01/09/25 at 10:00 AM, Staff C, Registered Nurse (RN), used the thermometer on Patient 3, then after using it, cleaned the thermometer and placed it back into the bag. Staff A cleaned the thermometer with the cleaning wipe without using gloves. Staff A then placed the dirty cleaning wipe on top of the clean thermometer and blood pressure cuff that was inside of the bag. Staff A removed the stethoscope from around Staff As neck and used it to obtain the blood pressure of the patient. Staff Adid not clean the stethoscope prior to using it on Patient 3. Staff A then applied lotion to Patient 3’s legs and applied a cleanser to her gloves instead of the lotion. Staff A removed the left glove, opened the clean bag of gloves and attempted to remove a glove from the bag. In doing so, Staff A touched the inside of the clean bag of gloves with Staff As right hand that was still gloved and dirty from touching Patient 3’s legs. Patient 10 During a home visit observation on 01/09/25 at 2:30 PM, Staff D, Hospice Aide, (HA), placed a clean barrier down on the table and proceeded to take out Staff Ds equipment out of the bag and placed it on the clean barrier. Staff D obtained the blood pressure of Patient 10 and then went over to the clean barrier and to obtain a cleaning wipe. In the process of obtaining this clean wipe, the dirty blood pressure cuff touched the clean barrier that had the clean thermometer and clean gloves on it. During an interview on 01/09/25 at 3:30 PM, Staff D stated, “I didnt realize the blood pressure cuff touched the clean barrier.” During an interview on 01/09/25 at 4:05 PM, Staff C, RN stated, “I was so nervous, I didn’t know that I put the dirty wipe down in my bag on top of my clean equipment. I should have taken off both of my gloves before touching the bag of clean gloves.” During an interview on 01/10/25 at 2:05 PM, Staff B, Director of Patient Services (DPS) stated, “The staff have been instructed to put all their dirty equipment in a large plastic bag, then after the visit, take the plastic bag to their cars to clean the equipment. The dirty equipment should not touch the clean barrier, and gloves should be worn while cleaning the equipment.” Staff E Document review of the personnel file for Staff E, Volunteer, showed Staff E was hired on 01/01/24 and had no documentation of an initial two-step TB upon hire, and/or Hepatitis B vaccine attestation form. During an interview on 01/10/25 at 5:00 PM, Staff A, Chief Operational Officer (COO), confirmed that the documentation was not present in the employee file and should have been.”