St. Croix Hospice

“Based on record review and staff interview, the hospice provider failed to develop an initial plan of care (POC) in consultation with the interdisciplinary group (IDG) that addressed all of the patient’s identified problems at admission, in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect symptom management, coordination of services, and the implementation of interventions to meet the needs of all the patients served by the provider. Findings included:RECORD/PATIENT #1:Review of the clinical record showed the patient was readmitted to hospice services on 08/26/2025 with a terminal diagnosis of chronic diastolic (congestive) heart failure (CHF; a decrease in the ability of the heart to pump blood) and a left humerus fracture (a break in the upper arm bone). Review of the initial comprehensive assessment dated 08/26/2025 at 3:28 PM, identified the following active problems and risks:- Severe agitation upon awakening, attempts to crawl out of bed;- PAINAD (pain assessment in advanced dementia; a tool used to assess pain in patients with advanced dementia who may have difficulty communicating their pain) score of 5 indicating active pain;- Cognitive impairment;- Bedfast status;- Moist skin, Braden score (score was 12) (an assessment tool used to determine a patient’s risk for developing pressure injuries (skin injury caused by unrelieved pressure);- Shortness of breath (dyspnea) with crackles (abnormal lung sounds made by air moving through a congested airway) in the lungs lower lobes;- Edema (swelling of the tissues) to bilateral ankles;- Constipation, last bowel movement was on 08/17/2025;- Hallucinations, confusion, and disorientation;- Incontinence;- Indwelling catheter (a sterile tube placed in the bladder to drain urine);- Dependence on a single caregiver;- Sensory impairment that limited communication;- Use of opioids (relieves moderate to severe pain), oxygen, and anxiolytics (used to reduce anxiety, agitation, restlessness, and distress); and- Rapid decline.- The patient died on 08/30/2025. Review of the initial POC failed to include interventions for:- Severe agitation, delirium, hallucinations, or behavioral symptoms;- High fall risk and attempts to exit the bed;- Pain management needs based on PAINAD findings;- Constipation requiring a bowel regimen;- Pressure injury prevention for a Braden score of 12;- Respiratory symptoms including crackles, dyspnea, and congestive heart failure (CHF) related distress;- Caregiver strain and the need for support resources;- Sensory impairment that affected communication; - Indwelling catheter management and beyond generic instruction; and- The POC failed to correspond to the patient’s assessed problems/needs. During an interview on 11/17/2025 at 9:45 AM, the administrator stated that the plan of care was set up on admission and adjusted by the case manager. The plan of care should have reflected the assessment and should have been individualized.”

“Based on clinical record review, and staff interview, the hospice provider failed to ensure an interdisciplinary group (IDG) developed and maintained an individualized, comprehensive plan of care (POC) that reflected the patient’s assessed problems, goals and required interventions, in one of three records reviewed (Record/Patient #2). This deficient practice has the potential to result in unmet needs and inadequate coordination of care for all the patients served by the provider. Findings included:RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of chronic pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home, alone, and had the following medical devices/equipment: - A permanent pacemaker (a device that uses low energy electrical pulses to correct a slow heart rhythm, helping the heartbeat at a normal rate);- Implantable defibrillator (a device that monitors for dangerous, fast heart rhythms and delivers a high-energy shock to restore a normal beat if one is detected);- BiPAP (bilevel positive airway pressure machine, a non-invasive device that provides breathing assistance by delivering pressurized ear through a mask or nasal plugs) used at night;- Dexcom continuous glucose monitor; and- Omnipod insulin pump (a system that delivers continuous injectable medication that lowers blood sugar). Review of the POC showed the provider failed to include the patient’s pacemaker, defibrillator, BiPAP, and Dexcom. The POC also failed to include individualized interventions, instructions, and limits for each device. Review of the nurse’s note dated 09/24/2025 at 1:37 PM, showed the following:- Non-pitting edema (swelling of the tissues) in both arms;- Oxygen required at night;- Two falls related to tripping over a puppy;- The patient went to the emergency department for a dislocated kneecap; and- Left knee swelling, bruising, and a knee sleeve (provides compression and warmth to the knee joint to improve blood flow, reduce swelling, and offer mild to moderate support) in place.The provider failed to update the POC to include edema, oxygen use, history of falls with injury, knee sleeve and related interventions. Review of the nurse’s note dated 09/29/2025 at 12:16 PM, showed the following:- The patient could not connect to the Omnipod and Dexcom to a new phone;- The family attempted to contact the endocrinologist; and- Registered nurse (RN)-A obtained orders for short-acting insulin, blood sugar checks before meals and at bedtime, and a “medium” sliding scale (a blood sugar sliding scale, which is a medical guideline used to determine the dose of rapid or short-acting insulin to administer based on a patient’s current blood glucose level). The provider failed to update the POC to include the involvement of the endocrinologist, short-acting insulin, blood sugar monitoring, and sliding scale insulin regimen. Review of the nurse’s note dated 11/12/2025 at 12:58 PM, showed the following:- Increased bladder incontinence over four months; and- Low back rated up to 8/10 (eight out of 10, a numerical pain scale used to rate pain with zero representing no pain and ten representing the worst pain possible). The provider failed to update the POC to include the bladder incontinence and individualized pain interventions. During an interview on 11/17/2025 at 9:45 AM, the administrator stated that the plan of care was set up on admission and adjusted by the case manager. The plan of care should have reflected the assessment and should have been individualized.”

“Based on policy review, record review, and interview, the agency failed to ensure the care and services provided were in accordance with the plan of care (POC) in, two of three records reviewed (Patients #1 and #2). This deficient practice has the potential to affect care and services for all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Interdisciplinary Group Coordination of Care,” last revised December 2018, showed in part, the following:-The hospice interdisciplinary group (IDG) will retain professional management responsibilities for the provision of services, and will ensure that services are furnished in a safe and effective manner;- Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patient’s clinical record and will involve the hospice patient’s attending physician; and- The IDG will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 days. Review of the provider’s policy titled, “Verification of Physician Orders” last revised December 2018, showed in part, orders will be obtained from a licensed physician for care and services to be provided to hospice patients. RECORD/PATIENT #1:Review of the clinical record showed the patient was readmitted to hospice services on 08/26/2025 with a terminal diagnosis of chronic diastolic (congestive) heart failure (CHF; a decrease in the ability of the heart to pump blood), the patient resided at home with a primary caregiver (PCG), and the patient died on 08/30/2025. Review of the current POC/medication profile dated 08/26/2025, showed the following physician orders:- Haloperidol (antipsychotic) 0.5 mg (milligrams), one tablet at bedtime as needed;- Lorazepam (treats anxiety) 0.5 mg every four hours as needed for anxiety or shortness of breath; and- Morphine concentrate (used to treat severe pain) 100 mg/5 ml (milliliter) (20mg/ml), give 5 mg (0.25 ml) oral solution every four hours as needed for pain or shortness of breath. Review of the physician order dated 08/28/2025, showed haloperidol lactate (injection) 2 mg/2 ml oral concentrate, 2.5 mg administered sublingually (under the tongue) every eight hours as needed for agitation was obtained.Review of a nurse’s note dated 08/28/2025 at 9:10 AM, showed the registered nurse case manager (RNCM) documented lorazepam was being administered 0.25 “ml” (milliliter) every four hours. Review of the text messages provided by the administrator showed in part, the following text between RN - A and the patient’s PCG, on 08/28/2025 at 4:03 PM, RN A texted “How has (the patient) been today? Feel free to call on call this evening if you can’t settle (the patient) down. Remember to use lorazepam (antianxiety) every two hours as needed” (the current medication profile showed the lorazepam was ordered every four hours). The clinical record failed to include a physician order to increase the lorazepam frequency. Review of the nurse note dated 08/29/2025 at 11:39 AM, showed the following:- The patient was exhibiting a lot of restlessness in form of kicking legs, swinging legs off bed, attempting to bite caregivers/family members, and biting self;- The patient reached out into the air, verbalized “dad”, and had a far off gaze;- The patient could not be consoled or reasoned with;- The PCG reported he/she had been giving the patient “0.5 ml (10 mg) of morphine and 1 ml of lorazepam every two hours” simultaneously due to uncontrolled restlessness; and- The RNCM obtained verbal orders from the patient’s physician to utilize “0.5 ml morphine every hour and increase lorazepam 1 ml to hourly but will stagger the dosing 0.5 ml every 30 minutes” until the patient was calm. Haldol could be given every six hours as needed. The clinical record failed to include physician orders to increase the morphine and lorazepam dosage, failed to include physician orders to stagger the lorazepam doses until the patient was calm, and failed to include physician orders to increase the frequency of the Haldol. The clinical record also failed to include documentation that the physician was notified of the patient’s behaviors. During an interview on 11/17/2025 at 1:14 PM, the RNCM stated that:- The patient was alternating morphine and lorazepam because the RNCM thought the patient’s symptoms were anxiety, so he/she staggered the lorazepam, and got the patient comfortable;- The RNCM received a text from the PCG on Thursday (08/28/2025) at 6:00 PM and the PCG caregiver texted that “they” had increased doses and were alternating every two hours;- He/she went to visit the patient on Thursday (08/29/2025) and increased the morphine to 1 ml (20 mg) an hour and to stagger the dose of Ativan (lorazepam) to 0.5 ml every 30 minutes;- He/she did not write an order for morphine 1 ml because the family had the medication in the house; and- The patient’s physician was ok with staff giving morphine 1 ml hour and anything more than that, and the physician would have to be notified. During interview on 09/18/2025 at 9:15 AM, the registered nurse coordinator stated that the nurse only documented the medication changes in his/her note and did not write a verbal order for the physician to sign. RECORD/PATIENT #2:Review of the clinical record showed the following:- The patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of chronic pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and other pertinent diagnoses included type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with hyperglycemia (high blood sugar); and- The patient had a Dexcom (continuous glucose monitoring system); and- The patient resided at home alone. Review of the nurse’s note dated 09/29/2025 at 12:16 PM, showed the following:- The patient could not connect to the Omnipod (a system that delivers continuous injectable medication (insulin) that lowers blood sugar) and the Dexcom to a new phone;- The family attempted to contact the endocrinologist; and- The RNCM obtained orders for short-acting insulin (regular insulin that starts to work quickly, and you take it before meals), blood sugar checks before meals and at bedtime, and a “medium” sliding scale (a medical guideline used to determine the dose of rapid or short-acting insulin to administer based on a patient’s current blood glucose level) until the Omnipod could be set back up.The clinical record failed to include physician orders for short-acting insulin, the sliding scale, and the parameters for a “medium” sliding scale. The POC also failed to include the endocrinologist. Review of the POC/medication profile dated 10/03/2025 through 12/01/2025 showed the following orders:- Hydrocodone 5 mg-acetaminophen 325 mg (used to treat moderate to moderately severe pain), one tablet every six hours as needed for pain;- Humulin 70/30 U (units)-100 insulin) KwikPen (a disposable pen that delivers insulin)100 unit/ml, special instructions inject up to 100 U into insulin pump daily to be injected subcutaneously (under the skin); an- Omnipod 5 (provides continuous insulin delivery through a tubeless, waterproof insulin pump called a Pod), place cartridge on upper arm and change pod every 72 hour.The POC failed to include a physician order for the Dexcom and the Omnipod settings (programmed instructions inside an Omnipod insulin pump that tell it when to deliver insulin and the amount that should be injected). Review of the nurse’s note dated 10/03/2025 at 12:45 PM, showed the following:- The patient was checking blood sugars four or more times daily;- Fasting blood sugars had remained 210 (normal blood sugar parameters are 80 to 130 before meals) or lower; and- Patient utilized a “medium” sliding insulin scale. The clinical record failed to include a physician order for blood sugar checks and the sliding scale with parameters. The skilled nurse failed to notify the physician of the elevated blood sugars. Review of the nurse’s note dated 10/20/2025 at 12:53 PM, showed the following:- The patient reported he/she had episode of high blood sugar yesterday (10/19/2025) then, after insulin administration, the patient’s blood sugar dropped from 300 to 50;- The patient called the EMS (emergency medical service), the patient was taken to the ER (emergency room) to be monitored, and no interventions were given, and the patient was sent home the same day without admission;- The patient stated that he/she had the Omnipod on and was administering short-acting insulin “on top of it”;- The RNCM instructed the patient not to utilize the sliding scale if the Omnipod was administering constant insulin, the sliding scale was in place as an alternative to the Omnipod;- The patient verbalized understanding and reported he/she would take the Omnipod off today; and- The patient did not have the correct Omnipod settings and plans to schedule appointment with endocrinologist to get the correct settings; The clinical record failed to include physician orders to discontinue or continue using the short-acting insulin while using the Omnipod, the sliding scale with parameters, the removal of the Omnipod, and the Omnipod settings.Review of the nurse’s note dated 10/22/2025, showed the following:- The patient still had not obtained Omnipod setting from endocrinologist and had been checking blood sugars before meals and hour of sleep; and- The blood sugars had a range from 120 to 200 in the last few days. The clinical record failed to include physician orders for the Omnipod settings, blood sugar checks before meals and hour of sleep, and the sliding scale with parameters. Review of the nurse’s note dated 11/12/2025 at 1:00 PM, showed the patient experienced pain in his/her lower back and the patient reported utilizing “Norco (hydrocodone; used to treat moderate to severe pain) 1.5 tablets daily for pain” at this time.The record failed to include a physician order for Norco 1.5 tablets, the physician order was for hydrocodone, one tablet. During an interview on 11/18/2025 at 9:45 AM, the RN coordinator stated that:- The short-acting insulin was put in the Omnipod;- The clinical record failed to show if the sliding scale was discontinued when the Omnipod was running;- The clinical record failed to show information regarding the sliding scale; and- He/she agreed with the findings and was unable to find any additional information in the clinical record. During an interview on 11/18/2025 at 9:45 AM, the administrator stated that:- The Dexcom attaches to the body and the Omnipod distributes the insulin;- He/she did not know what a “medium” sliding scale was;- There was no order for short-acting insulin or a sliding scale;- There was an order for hydrocodone 1 mg, one tablet every six hours as needed not hydrocodone 1.5 tablets as the nurse documented on 11/12/2025; and- He/she would expect the case manager to write clear and concise orders and discontinue things when no longer needed.”

“Based on policy review, clinical record review, home visit observation, text communication review and interviews, the hospice provider failed to ensure that the nursing services were provided in accordance with accepted standards of practice and in a manner that met the needs of the patient/family when it failed to:- Ensure the registered nurse (RN) to reassessed and intervened when a patient experienced uncontrolled pain, agitation, and functional decline;- Ensure physician notification, medication orders, and documentation were completed for significant changes in condition; and- Ensure diabetes management, insulin administration and device coordination were monitored, assessed, and reported appropriately.This failure resulted in unmanaged symptoms, unmanaged clinical risks, and lack of RN oversight when the patient’s condition declined in one of three records reviewed (Record/Patient #1) and failed to ensure another patient’s diabetes was managed, in one of three records reviewed (Record/Patient #2). These deficient practices have the potential to adversely affect the provision of care to all the patients served by the provider. FINDINGS INCLUDED: Review of the provider’s policy titled, “Interdisciplinary Group Coordination of Care,” last revised December 2018, showed in part, the following:- The interdisciplinary group is (IDG) responsible for safe and effective services;- The case manager is responsible for communication, coordination, ongoing assessments, and physician notification;- Documentation must include all communication and outcomes; and- Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week. Review of the provider’s policy titled, “Nursing Care,” last revised December 2018, showed in part, the following:- Nursing services are provided under RN supervision;- The hospice nurse will be a member of the IDG;- The RN plays a key role in symptom management and communication with the IDG;- The RN case manager is responsible for care coordination, ongoing evaluation, and communication with physicians;- The RN must document changes, obtain orders, ensure appropriate symptom management; and- RN services are available on a 24-hour basis. RECORD/PATIENT #1:Review of the clinical record showed the patient:- Was readmitted to hospice on 08/26/2025 with a terminal diagnosis of chronic diastolic (congestive) heart failure (CHF; a decrease in the ability of the heart to pump blood);- Recently discharged after a fall and readmitted with a left humerus fracture (a break in the upper arm bone);- Lived at home with a primary caregiver (PCG); and- Died on 08/30/2025.Review of a coordination note dated 08/28/2025 at 9:10 AM, showed the PCG reported that the lorazepam (antianxiety) was not effective and the patient experienced restlessness all night. The documentation failed to include physician notification.Review of a hospice aide note dated 08/28/2025 at 11:14 AM, showed a “vigil” (sitting at the bedside per the RN coordinators interview) was not done per the RN case manager’s (RNCM) instruction. The documentation failed to include a rationale for why the vigil was not performed. Review of the chaplain visit note dated 08/28/2025 at 11:27 AM, showed documentation that the patient had severe agitation and was unable to complete thoughts. The chaplain failed to document that he/she communicated this to the RNCM.The administrator provided text messages from 08/28/2025 between the RNCM and PCG that showed, in part, the following:- At 4:03 PM, the RNCM instructed the use of lorazepam every two hours and haloperidol (antipsychotic) at night, without documented physician orders;- At 5:59 PM, the PCG reported increased agitation, medication dose adjustments, and the aide assisted with dosing; and- The PCG later reported biting attempts and escalating agitation. The RN allowed the caregiver and home health aide to manage and adjust medications without documented oversight. The RN instructed the PCG via text to give lorazepam every two hours without a corresponding physician order or documentation in the clinical record. There was no RN visit made on 08/28/2025 despite repeated reports of escalating agitation, physical aggression, and uncontrolled symptoms. The text communication between the RN and caregiver was not incorporated into the clinical record.Review of the nurse note dated 08/29/2025 at 11:39 AM (17 hours and 36 minutes after repeated escalation), showed:- Continued severe restlessness, aggression, and inability to be consoled;- The PCG administering morphine and lorazepam every two hours;- The RNCM obtained verbal orders for hourly morphine and staggered lorazepam; and- Planned to adjust medications once calm. The clinical record failed to include written physician orders for dosing changes, documentation of patient response to interventions, and follow-up assessment of symptom relief. During an interview on 11/17/2025 at 12:22 PM, the hospice aide:- Confirmed the patient’s agitation;- Stated that he/she assisted the PCG with medications; and- Stated that he/she was unsure if communication with the RNCM was documented. During an interview on 11/17/2025 at 1:14 PM, the RNCM:- Acknowledged failure to visit the patient on 08/28/2025;- Confirmed uncontrolled pain and terminal restlessness;- Confirmed the patient’s alternated morphine/lorazepam without formal orders;- Stated that he/she did not write verbal orders for increased morphine; and- Acknowledged delays due to waiting on the RN coordinator. During interview on 09/18/2025 at 9:15 AM, the registered nurse coordinator stated that:- The RNCM should have visited the patient on 08/28/2025;- Confirmed the missing physician orders and lack of documentation regarding improvement; and- Confirmed the missing communication about the vigil and the chaplain’s concerns. During an interview on 11/20/2025 at 11:01 AM, the PCG stated that:- The reported escalating agitation began Wednesday (11/28/2025) and he/she believed the nurse should have visited;- Felt hospice could not manage symptoms;- The aide increased the morphine and relayed this to the RNCM; and- Felt “abandoned” and that the patient lost dignity in the final days. RECORD/PATIENT #2:Review of the clinical record showed the following:- The patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of chronic pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and other pertinent diagnoses included type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with hyperglycemia (high blood sugar);- The patient lived alone; and- The patient had a Dexcom (continuous glucose monitoring system) (The record failed to include a physician order for the Dexcom). Review of the nurse’s note dated 09/2/2025 at 1:37 PM, showed the RNCM documented a fall with knee injury, emergency room (ER) visit, and swelling. The clinical record failed to show physician notification of a fall with injury. Review of the nurse’s note dated 09/29/2025 at 12:16 PM, showed difficulty connecting the Omnipod (a system that delivers continuous injectable medication (insulin) that lowers blood sugar) and the Dexcom and the family was contacting endocrinology. The RNCM initiated blood sugar checks and a “medium” sliding scale (a medical guideline used to determine the dose of short-acting insulin to administer based on a patient’s current blood glucose level)The clinical record failed to include physician orders for short-acting insulin, sliding scale parameters, and a follow-up with endocrinology.Review of the nurse’s note dated 10/03/2025 at 12:45 PM, showed frequent blood sugar checks and use of sliding scale. The documentation failed to show insulin doses (sliding scale), follow-up on the malfunctioning equipment the Omnipod and Dexcom), and physician notification.Review of the nurse’s note dated 10/06/2025 at 12:24 PM, showed the patient was symptomatic with weakness, imbalance, and headache. The blood sugar was 195 (normal blood sugar levels are 80-130 mg/dl (milligram/deciliter) and 180 mg/dl two hours after meals). The clinical record failed to show physician notification.Review of the nurse’s note dated 10/08/2025 at 2:24 PM, showed the patient was still symptomatic and reported feeling sick, achy muscles, and headache. The documentation failed to show the RNCM assessed the patient’s blood sugars or device status and physician notification. Review of the nurse’s note dated 10/20/2025 at 12:53 PM, showed:- The patient reported he/she had episode of high blood sugar yesterday (10/19/2025), then after insulin administration the blood sugar dropped from 300 to 50;- Emergency medical system (EMS) was called, and the patient was taken to the ER;- The patient was using the Omnipod while also using sliding scale;- The RNCM instructed to discontinue the sliding scale while the Omnipod was active; and- The patient lacked the correct Omnipod settings. The documentation failed to show the physician was notified of the hypoglycemia (a condition in which a patient’s blood glucose level drops too low, generally below 70 mg/dl) / hyperglycemic event, clarification of insulin orders, and device management follow-up.Review of the music therapy note dated 10/21/2025 at 11:00 AM, showed the patient expressed frustrations with devices (the Omnipod and Dexcom) and the failure of the registered nurse (RN) to follow-up.Review of the nurse’s note dated 10/22/2025, showed the patient still did not have the Omnipod settings and the nurse failed to notify the physician. Review of the nurse’s note dated 11/10/2025 at 11:48 AM, showed the patient had loose stools and stomach cramps. The clinical record failed to show physician notification and follow-up. Observation on 11/17/2025 at 1:36 PM, showed the RNCM failed to assess the patient’s blood sugar, the Omnipod, the Dexcom, or the sliding scale insulin use. During an interview on 11/18/2025 at 9:45 AM, the RN coordinator stated that:- The short acting insulin was placed in the Omnipod;- He/she agreed the clinical record lacked sliding scale insulin and necessary orders;- The clinical record failed to show information regarding the sliding scale; and- He/she was unable to locate additional documentation. During an interview on 11/18/2025 at 9:45 AM, the administrator stated that he/she:- Confirmed the lack of orders for short-acting insulin and sliding scale;- Noted the incorrect hydrocodone order in the record; and- Expected the RNCM to provide clear orders and discontinue outdated orders.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009 “Hand Hygiene” (reviewed 09/25/2024) stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: G. After removing gloves.” In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed as indicated per the agency’s policy. Home Visit 1: The patient elected hospice care on 09/13/2024 with a diagnosis of Alzheimer’s Disease. During the home visit on 10/30/2024 with the Registered Nurse (RN [Personnel Record 1], the RN cleansed their hands with an alcohol-based hand rub, donned gloves, removed the soiled dressing from the patient’s left heel, removed the gloves, and donned a new pair of gloves. The RN cleansed the left heel wound and applied a new dressing. The RN did not perform hand hygiene between the glove changes. During an interview on 10/31/2024, the Manager of Accreditation confirmed the finding and the agency policy that hands should be cleansed between glove changes.”

“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, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (reviewed 02/14/2024) read in part, “Hospice aide supervisory visits will be conducted on-site at least every two (2) weeks by a hospice registered nurse.” In 2 of 17 (12%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Clinical Record 1: The patient elected hospice care on 09/13/2024 with a diagnosis of Alzheimer’s Disease. The plan of care dated 09/13/2024 through 11/11/2024 ordered HA services twice (2) weekly beginning 09/15/2024. The HA visits were provided beginning 09/15/2024 as ordered. The HA supervisory visits were provided on 09/27/2024 and 10/16/2024, with 19 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 11: The patient elected hospice care on 12/16/2022 with a diagnosis of Alzheimer’s Disease. The recertification plan of care dated 08/07/2024 through 10/06/2024 ordered HA services twice (2) weekly beginning 08/12/2024. The HA visits were provided beginning 08/12/2024 as ordered. The HA supervisory visit was completed on 10/09/2024, with 65 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. In a joint record review and interview on 10/31/2024, the Manager of Accreditation confirmed that HA supervisory visits were not completed every 14 days per agency policy.”

“Based on policy review, record review, and interview, the provider failed to assess and/or document responses to symptom management and treatment in one of four records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers policy titled, “;Comprehensive Assessment”, dated last reviewed 02/20/2024, showed in part, during the comprehensive patient assessment, all baseline and other relevant information will be documented in the patients clinical record, including the current treatment and patient response to that treatment. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 04/03/2024, with the terminal diagnosis of cancer of the appendix and a secondary diagnosis of urinary tract infection. The patient resided at his/her home with a primary caregiver (PCG). Review of a nurse visit note report, dated 04/09/2024 beginning at 11:02 AM, showed the patients scrotum had a small open area, and the area was cleaned, and “;callusing” was applied. The assessment of the small open area on the scrotum failed to include the size, appearance, exact location, and what the area was cleansed with and the the correct spelling of the dressing applied. The clinical record failed to include any further assessment of the patients scrotum after 04/09/2024. Review of the nurse PRN (as needed) visit, dated 04/10/2024 beginning at 10:55 PM, showed the patient had history of a urinary tract infection (UTI). The patient had an indwelling/suprapubic catheter (a medical device that helps drain urine from the bladder) and nephrostomy tube (a tube that drains urine from the kidney). The indwelling catheter was flushed with normal saline or sterile water as needed for non-patent catheter, with return of cloudy amber urine with large amount of mucus. The current Foley catheter (drains urine from the bladder) was removed, and a new Foley catheter was placed. The patient had anxiety related to chest pain and shortness of air earlier this evening and when Foley catheter was replaced. Review of a client coordination note report, dated 04/11/2024 (no time), showed that there was a moderate amount of amber urine noted in the nephrostomy tube drainage bag. The Foley catheter tubing had a large amount of mucus and sediment noted in small amount of urine. There was an order to do UA (urinalysis) with culture and sensitivity (a test that checks for bacteria in urine that could be causing a UTI) and was collected after the Foley catheter was changed. Review of a nurse visit note, dated 04/12/2024 beginning at 1:40 PM, showed abnormal findings with the indwelling/suprapubic catheter and nephrostomy tube, there was no further documentation to show what the abnormal findings were. The narrative showed the PCG stated that the patients Foley catheter was changed 04/11/2024 (the nurse note showed the Foley catheter was changed on 04/10/2024) and the patient was feeling better and there was no sediment in the urine per the PCG. The skilled nurse failed to document any further information related to the patient’s urinary status to determine if any signs and symptoms of a urinary infection were present. . Review of a nurse visit note, dated 04/16/2024 beginning at 4:04 PM, showed abnormal findings with the indwelling/suprapubic catheter and nephrostomy tube, there was no further documentation to show what the abnormal findings were. The RN failed to document any further information related to the patient’s urinary status to determine if any signs and symptoms of a urinary infection were present. The documentation failed to include follow-up of the UA obtained on 04/11/2024. Review of a client coordination note dated 04/18/2024 (two days after the assessment and one day after the patient was hospitalized), late entry for 04/16/2024, showed the patient had a Foley catheter and denied symptom of a UTI “;besides hurting thinking from pulling at the site of insertion” (failed to include the assessment of the insertion site). The urine was dark yellow clear and no sediment. The documentation failed to include any follow-up of the UA obtained on 04/11/2024. Review of a discharge visit note, dated 04/17/2024 beginning at 6:00 AM, showed the patient had “no active infections currently” (there was no UA results obtained), and was admitted to the hospital on 04/17/2024. A report was called to the hospital social worker, unsure of diagnosis to hospital but patient’s caregiver stated that it was from a UTI/fungal infection. The provider was unsure if it was from the nephrostomy tube and needed changed. The reason for discharge was the patient moved out of the hospice service area. Review of the client coordination notes, dated 04/17/2024, the following: - Untimed, the patients family member stated the patient was in the emergency room and reported chest pain that was believed to be muscular issue and not cardiac. “;They called her back shortly after states PT (patient) BP (blood pressure) had dropped and PT may be septic. Cefepime (antibiotic that can treat bacterial infections) was given, and PT was allergic to the medication. ER (emergency room) states they may transfer PT to [hospital] to treat. [Spouse] unsure if she wants to do that or send PT home. She is heading back to ER now and will call with updates”; and - Untimed, the hospice provider received a call from the patients spouse who reported the patient had a UTI and fungal infection and will be transferred to the [hospital] for treatment and to change the nephrostomy tube. Review of the client coordination notes, dated 04/18/2024, showed the following: - Untimed, the patient went to the hospital on 04/17/2024 for chest pain, “;thought it was muscular but transferred to [hospital] for UTI/fungal infection and discharged from hospice service due to admittance to [hospital]”; and - Untimed, the on-call nurse documented the patients family member called to report the patient was still in the hospital and uncertain of discharge. He/she was wondering if patient can continue IV antibiotics after returning home. The caller concerned that UTI may have started due to the catheter changed infrequently. The caller requested that the urinalysis and culture and sensitivity results from last week to be faxed to the fax number provided. The registered nurse case manager (hospice) was to follow-up. The clinical record failed to include any follow-up. During an interview on 05/14/2024 at 10:29 AM, the registered nurse case manager (RNCM) stated that they had done a UA and changed the patient’s catheter. The patient’s caregiver asked what the UA showed and RNCM called the clinical director to ask if the results had been received. He/she did not assess the area on the scrotum but the “skin looked good around the area”. During an interview on 05/14/2024, beginning at 5:34 PM, the clinical director stated that the on-call nurse obtained the UA on 04/11/2024 and did not drop it (the UA) off at the lab. The patients family member took the patient to the ER on 04/17/2024 because he/she was having chest pain and it was determined the patient had a UTI and the patient was sent to another [hospital] to have the nephrostomy tube replaced. He/she did not know what the nurse meant on the 04/09/2024 assessment that showed the scrotum was treated with “callusing”, the nurse did not proofread. During an interview on 05/14/2024 at 10:00 AM, the administrator stated that there was not an order for the patients area on his/her scrotum. He/she would expect nurses to assess every wound. Staff were expected to document the same day the assessment was performed. The UA was obtained on 04/11/2024 and was not dropped off at the lab and there was no follow-up.”

“Based on policy review, record review, and interview, the provider failed to ensure physician orders were obtained and/or physician orders were followed, in four of four records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Review of the provider’s policy titled, “Verification of Physician Orders” dated December 2018, showed in part, the following: - To ensure that accurate physician orders are obtained in accordance with applicable law; ` - Orders will be obtained from a licensed physician (or other authorized independent practitioner), a qualified individual will review each order or prescription before care is provided; and - Orders will be documented in the electronic medical record (EMR), dated, signed by the professional receiving the order. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 01/25/2024 with a terminal diagnosis of coronary artery disease (damage or disease in the hearts major blood vessels). The patient resided at a long-term care facility (LTCF). Review of a client coordination note report showed the following: - On 02/17/2024 at 4:02 PM, the LTCF called and reported the patient was having urinary tract infection (UTI; an infection in any part of the urinary system) symptoms with decreased urine output that was “;slimy thick, dark brown in color”. The patient’s primary physician was contacted and ordered Bactrim (antibiotic) and a urinalysis (UA, used to test urine); and - On 02/18/2024, untimed, showed the hospice nurse called the LTCF and according to the LTCF nurse the patients urine was thick, purulent (consisting of, containing, or discharging pus), and appeared in pain while straight cath (catheter) (tube used to drain the bladder) was performed. The clinical record failed to include physician order for the Bactrim, the UA, and the straight cath. The clinical record failed to include the UA results. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 04/03/2024 with the terminal diagnosis of cancer of the appendix and a secondary diagnosis of urinary tract infection. The patient resided at home with a caregiver. Review of a nurse visit note dated 04/09/2024, beginning at 11:02 AM, showed that the patients scrotum had a small open area, and the area was cleaned, and “;callusing” applied. The clinical record failed to show an order for the treatment to the patients scrotum. Review of a client coordination note report, dated 04/11/2024 (no time), showed that there was a moderate amount of amber urine noted in the nephrostomy tube (a tube that drains urine from the kidney) drainage bag. The Foley catheter (drains urine from the bladder) tubing had a large amount of mucus and sediment noted in small amount of urine. There was an order to do a UA with culture and sensitivity (a test that checks for bacteria in urine that could be causing a UTI) and was collected after the Foley catheter was changed. The clinical record failed to show lab results from the UA. Review of the client coordination notes showed the following: - On 04/18/2024, the patient went to the hospital on 04/17/2024 for chest pain, “;thought it was muscular but transferred to [hospital] for UTI/fungal infection and discharged from hospice service due to admittance to [hospital]”; and - On 04/18/2024, the on-call nurse documented the patients family member called to request that the UA and culture and sensitivity results from the previous week be faxed (the UA was not taken to the lab and there were no results to fax). The registered nurse case manager (hospice) was to follow-up. The clinical record failed to show any follow-up. During an interview on 05/14/2024 at 5:34 PM, the clinical director stated that the on-call nurse obtained the UA on 04/11/2024 and did not drop it off at the lab. The patients family member took the patient to the ER on 04/17/2024 because he/she was having chest pain and it was determined the patient had a UTI and the patient was sent to another [hospital] to have the nephrostomy tube replaced. During an interview on 05/14/2024 at 10:00 AM, the administrator stated that there was not an order for the patients area on his/her scrotum. The UA was obtained on 04/11/2024 and the nurse did not drop the UA off at the lab and there was no follow-up (the nurse failed to follow physician orders). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/19/2024 with the terminal diagnosis of ischemic cardiomyopathy (a condition where the heart has aa reduced ability to pump blood due to damage to the heart muscle from ischemia). The patient resided at home with a caregiver. Review of a client coordination note dated 04/23/2024 at 1:48 PM, showed that the patients caregiver reported the patient woke him/her up overnight with “;burning” to his/her peri-area. The nurse was unable to obtain “;a hat” (used to collect urine) that day and would deliver a hat the next day and attempt to collect repeat UA, the patient and caregiver were in agreeance. Review of an infection report showed the patient had cloudy foul urine and a urine analysis was ordered 04/23/2024. The clinical record failed to show an order for a UA. Review of a client visit note, dated 05/07/2024 beginning at 12:44 PM, showed that the genitourinary (urinary and reproductive systems of the body) findings were abnormal and “;burning” was documented. Review of UA culture lab result that was faxed on 05/09/2024, showed the UA was collected on 05/07/2024 and received on 05/08/2024. The lab received a preserved urine culture transport tube with either no order indicated or a source which was inappropriate for the test requested. A urine culture was not performed. The clinical record failed to show an order for a UA. During an interview on 05/14/2024 at 9:27 AM, the clinical director stated that there was no order for the UA on “;04/24/2024”. The nurse was responsible to follow-up. There was no follow-up from the UA on 05/07/2024. During an interview on 05/14/2024 at 9:45 AM, the administrator stated that there was no physician order for the UA on 05/07/2024. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/09/2023 with the terminal diagnosis of atherosclerotic heart disease of native coronary artery (a narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart) without angina pectoris (chest pain). The patient resided in a LTCF. Review of a client coordination note dated 03/14/2024, showed three plus pitting edema (a type of swelling caused by fluid buildup and graded on a scale of 1-4 based on the depth of the indentation and how long it lasts after pressing on the swollen area) in bilateral lower extremities and the physician increased the patients Lasix (diuretic) to 40 milligram (mg) daily for five days. The clinical record failed to show an order to increase the Lasix to 40 mg daily for five days. Review of the clinical record showed a chest x-ray was to be obtained on 04/08/2024. The clinical record failed to show an order for the chest x-ray and failed to show results of the chest x-ray. During an interview on 05/14/2024, the clinical manager stated that he/she was printing the interdisciplinary teams minutes and there was no discussion of the patients breathing issues. During an interview on 05/14/2024, the administrator stated that there was no order for Lasix 40 mg, only for Lasix 20 mg every day, and there was no order for a chest x-ray and there was no results of a chest x-ray. He/she would expect staff to obtain an order for a chest x-ray and document this in the clinical record.”

“Based on policy review, record review, and interview the provider failed to forward a complete discharge summary to an accepting hospital, in one of one patient record reviewed for discharge (Record/Patient #2). This deficient practice has the potential to affect the post-hospice medical care of all the provider’s live discharged patients. Findings included: Review of the provider’s policy titled, “Discharge Summary,” dated revised 12/2018, showed in part the following: - Purpose: To establish standards by which patients are discharged for the hospice program; - When a patient is discharged, transferred, or referred to another organization, relevant information will include: * A reason for transfer or discharge * Specific medical, psychosocial, or other problems requiring interventions or follow-up * Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services * A copy of the current plan of care * A copy of the medication profile * The latest physician orders * Continuing symptom management needs * Follow-up to be provided by an interdisciplinary team member from the service transferring the patient * All pertinent laboratory data * The date of discharge, which is the date of the last visit made - Information will be documented in the clinical record, which is to be completed within 72 hours; and - In the event of a transfer, a copy of the discharge summary will be provided to the receiving facility, as appropriate, to ensure continuity of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 04/03/2024 and discharged to the hospital on 04/17/2024. Review of a discharge visit note, dated 04/17/2024 beginning at 6:00 AM, showed the patient had “no active infections currently” (there was no UA results obtained), and was admitted to the hospital on 04/17/2024. A report was called to the hospital social worker, unsure of diagnosis to hospital but patient’s caregiver stated that it was from a UTI/fungal infection. The provider was unsure if it was from the nephrostomy tube and needed changed. The reason for discharge was the patient moved out of the hospice service area. The clinical record failed to show a discharge summary and/or that one was sent to the hospital. During an interview on 05/14/2024 at 10:51 AM, the clinical director stated that the social worker at the hospital called the hospice nurse to get report and he/she thought that was the discharge communication. No additional information was provided.”