Glacial Ridge Hospice

“Based on interview, and document review, the agency failed to ensure a comprehensive medication review of all client prescription and over-the-counter medications was completed for 1 of 3 patients (P5) whose medications were reviewed, during a home visit. Findings Include:P5’s Plan Of Care (POC) dated 3/16/26 to 6/13/26, identified P5’s start of care date was 3/16/26, with a terminal diagnosis of acute kidney failure. P5’s visit orders included nursing once every week for thirteen weeks and twelve visits as needed (PRN). P5’s POC also included visit orders for aide visits once every week for thirteen weeks and seven PRN. Nursing care plan included medication reconciliation. P5’s Agency Medication Profile Report dated 4/27/26 identified the following:Olanzapine 10 milligrams (mg) oral tablet, take one tablet daily at bedtime for agitationDuring a home visit on 4/28/26 at 7:45 a.m., with home health aide (HHA)-A personal cares were observed in P5’s skilled nursing facility (SNF) room. P5’s SNF Medication Review Report dated 4/28/26, obtained at 8:49 a.m. a current medication listing was obtained from the SNF licensed practical nurse., identified the following:Olanzapine (antipsychotic medication) oral tablet, give 5 mg by mouth one time a day for agitation. Dulcolax Rectal Suppository (Bisacodyl-stimulant laxative) insert 10 mg rectally as needed (PRN) for constipation every other day (QOD)During a phone interview on 4/29/26 at 9:30 a.m., registered nurse (RN)-A confirmed she was P5’s nurse and reconciled P5’s medication. RN-A stated her usual practice was to reconcile patient’s medications every three months for their recertification or if a medication was added or changed. RN-A stated had thought P5’s olanzapine was ordered when P5 was admitted and the Dulcolax order must have been added by the SNF from standing orders. RN-A indicated the SNF had not notified her of any new orders, and she relied on the SNF to notify her of changes, since RN-A did not have access to the SNF electronic medical records. RN-A stated it was important to reconcile P5’s medications to assure right dosage and right medications were administered, and potential interactions could be harmful to P5. During interview on 4/29/26 at 11:53 a.m., hospice manager (HM)-A verified P5’s medication orders were not reconciled with the SNF medication orders. HM-A indicated expectation that patient medications would be reconciled to avoid medication errors. At 12:15 p.m., HM-A stated P5’s olanzapine order was a transcription error during hospice admission, and the facility must have added the Dulcolax from their standing orders. The agency Medication and Treatment Management policy reviewed October 2025, identified the client’s medical record would be monitored for potential drug interactions with each new certification period and with any new medication orders. Nursing management of medications included verifying correct medications. At each routine visit, the nurse would ask the client if there were any new medications or changes in current medications.”

“Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 1 of 8 patients (P3) who received home health aide services and who’s records were reviewed. Findings Include:P3’s Plan of Care (POC) dated 3/31/26 to 6/28/26, identified P3 began hospice services on 3/31/26. PC had a terminal diagnosis of hypertensive heart disease with heart failure. P3’s visit orders included aide visits once every week for thirteen weeks and ten visits as needed (PRN). P3’s POC also included nursing visits one every week for twelve weeks and twelve visits PRN. P3’s medical record identified P3 began aide services on 4/1/26. P3’s registered nurse (RN) visits were completed on 3/31/26, 4/8/26, and 4/15/26. P3’s RN visit notes identified aide supervision assessments were not performed. A phone interview was attempted on 4/29/26 at 9:15 a.m. and 11:20 a.m., with RN-B, but there was no answer. During interview on 4/29/26 at 11:55 a.m., hospice manager (HM)-A verified P3 had aide visits without RN supervision and identified her expectation was that RN visits would include supervision of aides as required. The agency Home Health Aide Supervision policy, reviewed/revised October 2025, identified all clients required supervision or monitoring of aide tasks within fourteen days after initiation of cares to determine if the home health aide was performing tasks and response of the client. The supervisory visit would be documented and if a deficiency in aide services was verified during the RN on-site visit, then the home health aide must complete retraining and a competency evaluation for the deficient and all related skills.”