Hospice of the Bluegrass, Inc. DBA Bluegrass Care N

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 home visit observation, and interview. In 3 of 23 (13%) clinical records reviewed, for the community program, in which hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the the aide to perform the patient’s required care. CLINICAL RECORD 1/HOME VISIT 1: The hospice election of benefit form was dated 09/13/2025 with a primary diagnosis of respiratory failure. The hospice aide visits were performed 2 times a week since admission 09/13/2025. Tasks assigned each visit were for bed bath and skin care every visit. The patient was admitted with a coccyx wound which deteriorated 09/20/2025. There were dressing on the coccyx since admission and the dressing was not on the plan of care for the aide to be notified as what to do if the dressing was off or saturated and who to report to, as of the home visit on 12/09/2025 with Personnel Record 1. CLINICAL RECORD 12: The hospice election of benefit form was dated 06/05/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. The hospice aide assignment documented 06/05/2025 with an ordered frequency of 2 times a week ordered bath task was chair, tub, bed, and shower - provide bath as tolerated. The task was unclear for which bath was to be provided or who the decision maker was. The hospice aide documented the different baths at different visits and documented “bath as tolerated”. The patient’s status was documented as alert and oriented x 4. CLINICAL RECORD 21: The hospice election of benefit form was dated 10/30/2025 with a primary diagnosis of Vascular Dementia. The hospice aide assignment documented 10/30/2025 and updated 11/05/2025 documented the assigned tasks of shower, oral care, skin care, hair care, shampoo and peri care two times a week and PRN (as needed). The shower stated patient preference but the other tasks did not identify a decision maker related to the as needed. The patient had vascular dementia and was documented as confused. During interview with the management team on 12/10/2025 who reviewed the record, noted that the plans were not clear for the patient care required.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed for the community program in which hospice aides provided services longer than 14 days, it was revealed that the agency did not ensure that hospice aide supervision was documented every 14 days. CLINICAL RECORD 1: The first hospice aide visit was documented as performed 09/16/2025 with a frequency of 2 times a week. There was no supervision documented as of the review on 12/09/2025. CLINICAL RECORD 7: Hospice aide supervision was documented as performed 03/25/2025. No further supervision was documented until 04/22/2025 which was 28 days outstanding. CLINICAL RECORD 5: The hospice aide provided visits 3 times a week with supervision documented every 14 days. Supervision was documented on 10/07/2025 and then not until 10/23/2025 which was 16 days outstanding. CLINICAL RECORD 14: The first hospice aide visit was performed 11/11/2025. Aide supervision was documented 11/10/2025 and no aide had provided care. No further, aide supervision was documented as of 12/08/2025. CLINICAL RECORD 19: The hospice aide provided visits 2 times a week with supervision documented every 14 days from 08/14/2025 until 10/14/2025. No further supervision was documented as of the review date of 12/10/2025. CLINICAL RECORD 27: The hospice aide provided visits 5 times a week with the first aide visit documented on 04/29/2025. Supervision was documented on 05/05/2025 and not again until 05/28/2025 which was 9 days late. During interview with the management team on 12/11/2025 who reviewed the record, it was stated that the supervision had not been documented every 14 days.”

“Based on interview and review of the Emergency Preparedness Plan (EPP), the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect the 696 patients receiving care and services from the organization and hindered the organization’s ability to provide care and services and keep patients safe during an emergency. The findings include: Review of the facility’s EPP Communication Plan with the Policy and Procedure Improvement Analyst (PPIA); the Chief Hospice Office (CHO) and Chief Executive Officer (CEO) joined later; did not reveal any policy or procedure regarding the role of the facility if the Health and Human Services Secretary should declare a section 1135 waiver, just that a waiver would be requested. During an interview on 06/24/2024 at 12:03 PM, the CEO and CHO confirmed the EPP just stated they would request a waiver, however there were no policies or procedures the facility would follow.”

“Based on interview and review of the Emergency Preparedness Plan (EPP), the facility failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included all location staff members and patient physicians. This failure had the potential to affect the 696 patients receiving care from the organization and could delay the facility’s ability to respond to an emergency. The findings include: Review of the facility’s EPP Communication Plan with the Policy and Procedure Improvement Analyst (PPIA); the Chief Hospice Office (CHO) and Chief Executive Officer (CEO) joined later; showed the plan did not include identification of all the facility’s staff and their contact information (only administrative staff were identified), nor did it include a list of patient physicians and their contact information. While looking for a staff member contact list, the PPIA left the Emergency Plan web area and opened the organization Share Point to locate something for staff members; the CEO stated, “each face sheet contains the physician and phone number.” When asked if the face sheets were contained in the Emergency Plan, the CHO responded, “No, we don’t print them weekly, they would be in the employee list.” When a request was made for the facility employee list with physicians at 12:31 PM on 06/24/2024 the CEO stated, “I wouldn’t go to the policy [clarified, EPP), I would go to other resources – which is all the things we’ve been talking about.””

“Based on interview and review of the Emergency Preparedness Plan (EPP), the facility failed to maintain a current list of contact information that included the Federal and legible Local emergency preparedness staff and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential to affect any of the 696 residents receiving care in the facility and would delay the facility’s ability to respond to an emergency and the potential to prevent first responders and other sources of assistance from providing care and services to the facility and its patients or staff during an emergency event. The findings include: Review of the facility’s EPP Communication Plan with the Policy and Procedure Improvement Analyst (PPIA); the Chief Hospice Office (CHO) and Chief Executive Officer (CEO) joined later; showed no inclusion of emergency contact information for the Federal emergency staff/agencies, and the map of the “Kentucky Regional Hospital Preparedness Program Coalition Readiness Response Coordinators” with contact information was illegible. During review on 06/24/2024 at 12:42 PM, the CEO directing the PPIA went to a page of “County Emergency Management Offices” that brought up a list of county directors with links to websites, Facebook, and Twitter accounts, but no direct phone numbers; the PPIA confirmed the page did not include phone contact numbers in the EPP.”

“Based on medical record review, interview, and policy review, the facility failed to ensure that effective pain management was provided to two patients (Patient (P) 1 and P21) of 14 active patient records reviewed. This deficient practice had the potential to affect all 696 patients receiving care from the facility. The findings include: 1. Review of P1’s medical record, in the Care Plan section of the Electronic Medical Record (EMR), the nursing documentation revealed the following: On 04/02/2024, P1 received a nursing visit. The nurse documented “pt. states that [his/her] pain is a +7 on pain scale today. [The doctor] did increase [P1’s] gabapentin (medication used to treat neuropathic pain) to 200 mg tid (200 milligrams three times a day) to see if this is effective with the pain, is on fentanyl (narcotic pain medication) 200 mcg (micrograms), oxycodone (narcotic pain medication) 30 mg 5 times a day, naproxen (pain medication) as well as decadron (a steroid used to treat pain).” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of seven out of 10 (zero indicates no pain and 10 indicates the highest level of pain) until seven days later. On 04/09/2024, P1 received a nursing visit. The nurse documented “pt. states that [his/her] pain is a +8 on pain scale today. Does feel that gabapentin has helped some, is on 200 mg tid, oxycodone 30 mg 5 times a day, fentanyl 200 mcg.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of eight out of 10 until seven days later. On 04/16/2024, P1 received a nursing visit. The nurse documented “states that pain is +7 on pain scale, states does take gabapentin 200 mg tid, oxycodone 30 mg 1 tab 5 times a day, fentanyl 200 mg, naproxen as well.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of seven out of 10 until seven days later. On 04/23/2024, P1 received a nursing visit. The nurse documented “Patient rating pain 7 on pain scale, patient taking Gabapentin 200 mg TID, Oxycodone 30 mg 5x daily and Fentanyl 200 mg, Naproxen BID (twice a day).” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of seven out of 10 until seven days later. On 04/30/2024, P1 received a nursing visit. The nurse documented “Patient rating pain 6/10 on pain scale, patient takes Gabapentin 200 mg, oxycodone 30 mg 5x daily and Fentanyl 200 mg, Naproxen BID.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of six out of 10 until nine days later. On 05/09/2024, P1 received a nursing visit. The nurse documented “Patient rating pain 7/10 on pain scale, patient takes Gabapentin 200 mg, oxycodone 30 mg 5x daily, Fentanyl 200 mg and Naproxen BID.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of six out of 10 until nine days later. On 05/14/2024, P1 received a nursing visit. The nurse documented “Pt. rates [his/her] pain +7 on pain scale, states that it was +8 this am, is agreeable to increasing [his/her] gabapentin to 300 mg at night, is also on gabapentin 200 mg in am and at noon, oxycodone 5 tabs a day, fentanyl 20 mcg, and naproxen bid, decadron 4 mg daily.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of seven out of 10 until seven days later. On 05/21/2024, P1 received a nursing visit. The nurse documented “pt. does state that the increase in the gabapentin to 300 mg has been more effective, continued on Fentanyl 200 mcg, oxycodone 30 mg 5 times a day, naproxen, decadron.” The pain assessment was incomplete as it did not include a reported pain level for P1 at the time of visit and did not include an acceptable pain goal for the patient. On 05/28/2024, P1 received a nursing visit. The nurse documented “pt does state that she forgot to take her ½ tab oxycodone earlier and just took the ½ tab. States that right now pain level is +9 on pain scale but did go down to +6 by end of visit.” The pain assessment was incomplete as it did not include an acceptable pain goal for P1. There was no follow-up on the patient’s reported pain level of six out of 10 until seven days later. On 06/04/2024, P1 received a nursing visit. The nurse documented “pt. complaining of increased burning pain, received order to increase [his/her] gabapentin to 300 mg tid, also added citalopram (an antidepressant used to treat pain) as well.” The pain assessment was incomplete as it did not include a reported pain level for P1 at the time of visit and did not include an acceptable pain goal for the patient. There was no follow-up on P1’s response to the changes made to the pain medication regiment until seven days later. 2. Review of P21’s medical record, in the Care Plan section of the Electronic Medical Record, revealed that on 06/19/24, P21 received a nursing visit. The nurse documented “pt stated [his/her] pain has gotten worse, and it comes back before next time to take meds. [He/she] is taking oxycodone every four hrs [hours] up to max of 8 tablets a day. Once [he/she] took 2 at the same time when she awoke with lots of pain in the middle of the night. New order from [doctor] for mscontin (a long-acting pain medication) 15 mg q12hrs (every 12 hours).” There was no follow-up on P21’s response to the changes made to the pain medication regiment until two days later. During an interview on 06/26/2024 at 8:50 AM, the Chief Hospice Officer (CHO) confirmed that for P1 and P21 the nurse did not perform a re-evaluation of the patients’ pain level and the changes made to the patients’ pain medication regiment in a timely manner. Review of the facility’s policy, effective 03/2023, titled “Pain and Symptom Management Guidelines” revealed “... Evaluation of pain and symptoms is required at every assessment visit by all professional staff utilizing age appropriate, discipline specific tools. If a new pain, symptom, or increases in current levels of pain and/or symptoms is reported to the professional staff a nurse or the appropriate healthcare professional associated with the symptom, must complete an assessment to evaluate the appropriate goal, intervention(s) and obtain appropriate orders ... Patients will be evaluated daily as needed by the interdisciplinary team until the patient reports their pain or other symptom levels are acceptable.””

“Based on observation, interview, and policy review, the facility failed to follow proper infection control guidelines while performing a bed bath for one (Patient (P) 22) of one observed hospice aide visits out of a total sample of 30 patients. The findings include: During an observation of care on 06/25/2024 at 8:38 AM, Home Hospice Aide (HHA)1 brought out two wash basins with water and placed them on an overbed table. Wearing gloves, HHA1 placed a washcloth in each basin and washed P22’s face with one of the washcloths then washed P22’s chest, arms, hands, and under arms. HHA1 repeated the process using the clean washcloth and clean water. HHA1 used a towel to dry the upper body, then uncovered the lower part of the body removing pressure relief boots, retrieved the first washcloth from the basin, added a squirt of Dial soap from the bottle, washed P22’s feet and legs, and used the other washcloth to rinse and then dried. At 8:49 AM, HHA1 did not change gloves or perform hand hygiene, did not change the water in the basin, and used the same washcloth to perform pericare, including wiping down P22’s foley catheter tubing. HHA1 then removed periwipes from the package with his/her gloved hands and performed incontinent care. After completion of incontinent care, HHA1 did not change his/her gloves or perform hand hygiene. HHA1 took the first wash basin to the bathroom to dispose of the water, repeated for the second basin, returned to the bedside, opened the wipes package, cleaned the overbed table with the periwipe, and disposed of gloves in the trash. HHA1 did not perform hand hygiene after removing the gloves and left the home. During an interview on 06/25/2024 at 9:00 AM, HHA1 confirmed that he/she did not change gloves and did not use a clean washcloth and clean water when performing pericare, including wiping down P22’s foley catheter tubing. HHA1 also confirmed that he/she did not change gloves and perform hand hygiene after performing incontinence care; and after completion of the visit did not perform hand hygiene after removing gloves. Review of the facility’s policy, effective 01/2024, titled “Hand Hygiene” revealed “... Use alcohol-based hand rub (AHBR) in the following circumstances: ... f. Before and after donning non-sterile or sterile gloves when providing direct patient care. g. Before a clean/aseptic procedure. ... j. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing if hands are not visibly soiled. k. If moving from a contaminated body site to a clean body site during patient care. l. Before completing a “dirty” task and starting a “clean” task such as emptying a urine Foley bag and performing a blood pressure check.””