Integrity Home Care + Hospice

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect the hospice provider’s ability to ensure safe and effective use of medications for all the patients served by the provider. Findings included:Review of the policy titled, “Medication Management and Administration,” dated revised 01/05/2026, showed in part:- “Named provider” has established procedures to ensure safe medication administration and management in the home;- Medication reconciliation should be completed on assessment and reassessment; see Client Assessment- Hospice policy;- Medication reconciliation includes: * Obtain information about medications currently being taken, in addition to those prescribed: over the counter medication, herbal preparations and dietary supplements; * Medication prescribed by another healthcare provider; * Use of illegal drugs; * Discuss any unresolved, significant concerns about the medication with the client’s physician/health care practitioner;- Reconcile all medications the client takes in the home against the medication list provided by the discharging facility or primary care provider; and- Verify that there are acceptable, written physician/healthcare practitioner’s orders for all medications that client is taking. Review of the policy titled, “Client Assessment- Hospice,” dated revised 06/03/2024, showed in part:- “Named provider” Interdisciplinary Group (IDG) conducts and documents a client- specific comprehensive assessment that identifies the client’s needs from their hospice care and services;- A start of care assessment is completed in the electronic medical record by a hospice registered nurse within 48 hours of election of Hospice care, unless the physician, client, or client representative request the initial assessment be completed in less than 48 hours. The assessment includes medication;- Drug profile (medication reconciliation) includes prescriptions, over the counter medications, supplements, herbal remedies, and other alternative treatments that could affect drug therapy which includes: identification of effectiveness of drug therapy, drug side effects, actual/potential drug interactions, duplicate drug therapy, and drug therapy related to laboratory monitoring. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/26/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition (a critical condition defined by extreme deficiencies in protein and caloric intake, leading to significant muscle wasting, fat loss, and potential edema). The patient resided at home with family caregivers.Observation and interview on 04/14/2026 at 8:30 AM, showed the following medication discrepancies with the provider’s medication profile:-The medication profile showed an order for acetaminophen (used to treat mild pain) 325 milligram (mg) tablets, take two tablets every four hours. The patient’s caregiver (cg) stated that the patient no longer took this medication;-The medication profile showed an order for acetaminophen 500 mg tablets, take two tablets every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for Advanced Eye Health (used to support retinal health, filter blue light, and reduce eye strain) 250 mg-2.5 mg- 0.5 mg capsules, take one capsule daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for bisacodyl (a stimulant laxative used for short-term relief of occasional constipation and to clear the bowels) 10 mg rectal suppository, use one suppository daily as needed. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for cyanocobalamin (a synthetic form of vitamin B12 used to treat and prevent deficiencies) 500 micrograms (mcg) tablets, take two tablets daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for dextrose 5% in water (a fluid used to treat dehydration, low blood sugar (hypoglycemia), and as a vehicle for medication administration - D5W) intravenously as needed for drugs incompatible with normal saline. The patient’s caregiver stated the patient no longer used this medication;-The medication profile showed an order for fenofibrate (a medication used to treat high cholesterol and high triglycerides by reducing fat production in the liver and boosting good cholesterol) 160 mg. The patient’s caregiver stated that the patient no longer took this medication;-The medication profile showed an order for hydrocodone 5 mg – acetaminophen 325 mg (a prescription combination of 5 mg hydrocodone (opioid) and 325 mg acetaminophen (non-opioid) used to manage moderate to severe pain) take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for hyoscyamine (an anticholinergic/antispasmodic medication used to treat stomach/intestinal cramps, irritable bowel syndrome, ulcers, and bladder spasms by relaxing smooth muscles) 0.125 mg sublingual (under the tongue) tablets, take one tablet every four hours as needed. The patient’s cg stated that the patient no longer took the medication;-The medication profile showed an order for laxative stool softener with senna (an over the counter medication containing a stimulant laxative and a stool softener) 8.6 mg – 50 mg tablets, take one tablet two times daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for levothyroxine (a synthetic hormone used to treat low thyroid hormone) 25 mcg tablets, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for melatonin (used to treat insomnia) 3 mg tablets, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for miralax (used to treat constipation) 17 gram/dose oral powder, use 17 grams daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for naloxone 0.4 mg/milliliter (mL) injection solution, inject 0.1-0.4 mg per physician instructions. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for ondansetron hydrochloride (used to nausea and vomiting) 4mg/2mL injection solution, take four mg intravenously every six hours as needed. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for pantoprazole (a proton-pump inhibitor used to treat heartburn and stomach ulcers by reducing stomach acid production) 20 mg tablets, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for promethazine (a prescription strength antihistamine used to treat allergy symptoms, motion sickness, nausea, and to provide sedation) 25 mg tablets, take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for simvastatin (a prescription statin medication used to lower high cholesterol and triglycerides) 20 mg tablets, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for sodium chloride 0.9 % flush (normal saline) injection syringe, use 10 mL every 12 hours for line patency. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for sodium chloride 0.9% flush injection syringe, use 10 mL before and after medication administration. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for sucralfate (a mucosal protectant used to treat and prevent duodenal ulcers) 1-gram tablets, take one tablet two times daily. The patient’s cg stated that the patient no longer took this medication; and-The medication profile showed an order for Tums Ultra (use to treat heartburn and acid indigestion) 400 mg chewable tablet, take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication.During an interview on 04/14/2026 at 12:00 PM, the administrator stated that the case manager saw the patient on 04/13/2026 and reconciled the medications and provided this surveyor with a new medication profile. The administrator also stated that the patient had a tuck-in visit on 04/10/2026 after returning home from respite and the medications should have been reconciled during that visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/26/2025 with a terminal diagnosis of combined systolic and diastolic heart failure (a severe condition where the heart muscle is both weak and stiff. This combination causes significantly reduced cardiac output often leading to pulmonary congestion (a dangerous accumulation of fluid in the lungs air sacs causing severe breathing difficulty, shortness of breath, and reduced oxygen intake). The patient currently resided in a long-term care facility (LTCF).Observation on 04/14/2026 at 8:58 AM, showed the following medication discrepancies between the hospice provider’s medication profile and the LTCF medication record: - The LTCF medication profile showed docusate sodium 100 mg (milligrams), two capsules every 12 hours as needed for constipation. The hospice provider’s medication profile showed docusate sodium 100 mg , one capsule twice daily as needed;- The LTCF medication profile showed loperamide HCL (hydrochloride) two mg, one tablet every four hours as needed for loose stools. The hospice medication profile showed loperamide 2 mg, two capsules at onset of diarrhea followed by one capsule as needed after each loose stool. Maximum of 16mg/day.- The LTCF medication profile showed Calcium 600/Vitamin D3 600-20 MG-MCG (microgram) give one tablet one time daily for supplement. The hospice medication profile failed to show calcium documented. During an interview on 04/16/2026 at 12:55 PM the administrator stated that the provider’s medication list should match the facility’s medication list. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/13/2026 with a terminal diagnosis of malignant neoplasm of overlapping sites of pancreas (pancreatic cancer). The patient resided at home with their spouse.Observation and interview on 04/14/2026 at 12:20 PM, showed the following medication discrepancies between the hospice provider’s medication profile and the patient’s home medication bottles.- The patient’s medication bottle showed clonidine 0.1 mg one tablet twice daily. The hospice provider’s medication profile showed clonidine 0.2 mg, one tablet two times daily. The patient stated that they took one of the clonidine 0.1 mg tablets twice daily;- The hospice medication profile showed Flintstone’s with iron 18 mg iron chewable one tablet and vitamin C 1,000 mg one tablet daily. The patient stated that they no longer took the Flintstone’s vitamins or the vitamin C and hadn’t for a couple months; and- There failed to be a bottle of apixaban. The patient stated that they were not taking it anymore and hadn’t for a couple months.- The referral information dated 02/03/2026 showed apixaban (a medication used thin blood to prevent blood clots) 5 mg take two tablets twice daily for six days, then take one tablet twice daily starting on 02/10/2026. The hospice medication profile failed to show apixaban documented. During an interview on 04/16/2026 at 12:55 PM the administrator stated that:- The patient had stopped taking the apixaban before admission because the patient had been falling at home and there failed to be any documentation of communication with the physician to clarify this;- The medication reconciliation had not been done correctly because the Flinstone’s vitamins and the vitamin C both should have been caught and not listed; and- He/she was unsure how the clonidine was listed as 0.2mg in the chart on the provider’s list.”

“Based on policy review, job description review, record review, and interview, the hospice provider failed to ensure clinicians followed their policies and procedures (P&P) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Communicating with Physicians,” dated revised 10/01/2024, showed in part:- There is ongoing communication with the client’s physician/health care provider when indicated, including written summaries throughout service delivery and at discharge;- Throughout the duration of service, whenever a change in client status occurs that requires the physician/healthcare provider to be notified, the communication will be documented; and- The method of communication should include communication of the situation, background information, assessment, and recommendations. Review of the “Job Description and Performance Evaluation: Registered Nurse- Hospice Services,” dated revised 05/11, showed in part:- Main function: A member of the hospice interdisciplinary group (IDG) who assures the delivery of quality care through responsible management of cases assigned, and coordination of services provided by all hospice IDG members;- Clinical responsibilities: initial and ongoing assessment of the impact of the terminal diagnosis on the client’s physical, functional, psychosocial, and environmental needs and activities of daily living;- Implementing the individualized plan of care (POC) and recommending revisions to the plan as necessary;- Informing the physician and other personnel of changes in the client’s needs and outcomes of intervention; and- Communicating information using current process and technology available to the organization RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/13/2026 with a terminal diagnosis of malignant neoplasm of overlapping sites of pancreas (pancreatic cancer). The patient resided at home with their spouse.Review of a skilled nurse visit note dated 04/01/2026, signed by a hospice registered nurse (RN) showed the patient reported a fall the prior Friday night getting up to go to the bathroom. He/she hit their head. A small scratch was noted on their head. No other injuries were noted at that time. The note failed to show documentation of notification to a physician, including the primary care physician listed on the patient’s POC. Review of a client occurrence report dated 04/01/2026 showed physician notified was marked, although it failed to identify what physician had been notified. During an interview on 04/16/2026 at 12:55 PM the administrator stated that he/she was unable to tell which physician was notified. During an interview on 04/16/2026 at 1:10 PM the administrator stated that he/she would expect the patient’s physician to be notified of a fall.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that physician’s orders were obtained prior to providing wound care in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Chart Data Requirements & Format – Hospice,” dated 06/02/2025, showed “The CMS (Centers for Medicare and Medicaid Services) home health certification and plan of care (POC) is (includes) the physician’s orders and documentation of the hospice care plan process for the care and services to be provided”.Review of the provider’s policy titled, “Job Description and Performance Evaluation Registered Nurse – Hospice Services,” dated 05/2011 showed the clinician’s responsibilities include implementing the individualized POC and recommending revisions to the plan as necessary.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 07/10/2025 with a terminal diagnosis of achondroplasia (an abnormal development of cells that hinders bone growth). The patient expired on 07/19/2025. The patient resided at home with a family caregiver.Review of the skilled nursing (SN) initial assessment, dated 07/10/2025, showed the patient had an unstageable wound to the left upper buttock. The SN cleansed the wound with wound cleanser and covered it with adhesive dressing. The note included instructions to change the dressing daily and PRN (as needed).Review of the POC dated 07/10/2025 – 09/07/2025, showed the POC failed to include wound care orders.Review of the SN visit note, dated 07/11/2025, showed the caregiver changed the dressing on the patient’s left buttock. The wound was still covered (with slough/eschar-dead tissue in a wound bed/dead tissue that is dry, tough, leather and black, tightly attached to the bound bed) and unstageable. There was a small amount of drainage on the dressing, and the wound had an odor.Review of the SN visit note, dated 07/14/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/15/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/16/2025, showed the SN cleansed the wound with wound cleanser and covered the wound with an adhesive dressing.Review of the SN visit note, dated 07/17/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/18/2025, showed the SN cleansed the wound with wound cleanser and covered the wound with an adhesive dressing.During an interview on 04/15/2025 at 3:30 PM, the administrator stated that he/she would expect there to be orders for any treatment that the patient was receiving and he/she could not locate the wound care order.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that volunteer services equal a minimum of five (5) percent of the total patient care hours of all paid hospice employees and contract staff. This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Volunteer Services- Hospice,” last revised 06/04/2024, showed in part, that the hospice provider would document and maintain volunteer staff sufficient to provide administrative or direct client care in an amount that, at a minimum, equals 5% of the total client care hours of all paid hospice employees and contract staff.Review of the hospice volunteer requirement report showed that the total percentage of volunteer hours was 3.40%.During an interview on 04/16/2026 at 1:00 PM, the administrator stated that, in February, a mandatory teams meeting was held to address the volunteer hours being less than 5%. Corrective action plans were discussed and a performance improvement plan was initiated to address the issue.”