Chi Health at Home - Omaha

“Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, 2 of 7 Staff observed (Staff-DD and Staff-R) failed to follow the agency policy and procedures for proper hand hygiene and glove use while providing cares to 2 of 7 patients (Patient- 1 and Patient 4 respectively). Seven observations were conducted. The total sample size was 28. The Census was 77 (including 11 inpatient hospice patients and 66 branch patients). Findings are: A. Review of the agency policy and procedure, specific to the inpatient facility, titled Infection Control/Standard and Universal Precautions, revised 8/2/22 revealed: 1. Staff were to complete hand hygiene before and after contact with patients, after contact with objects in the patient’s immediate area, when moving from contaminated body site to clean body site during care, and after removal of gloves.2. The policy also refers to Administrative 33.900, Hand Hygiene policy for further information. B. Review of the agency policy and procedure titled 33.900, Hand Hygiene revised 8/10/22 revealed:1. The purpose was to maintain cleanliness of the employees’ hands and to prevent cross-contamination and spread of infections. 2. Staff were to perform hand hygiene before and after direct patient contact, even if hands appear clean, before handling clean supplies, when moving from contaminated body site to clean site, between tasks on same patient, after removing gloves, before and after using the restroom, and before and after food preparation. C. Review of Patient 1’s Hospice Certification and Plan of Care for the certification period of 8/15/25 through 11/12/25 revealed orders for Skilled Nurse (SN) 2 times per week for 3 weeks, and 4 as needed visits for symptom management, patient/family support, complications related to disease condition. D. Review of Patient 4’s Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the certification period of 7/17/25 through 9/12/25 revealed facility staff to provide cares including assistance with showering/bathing, activities of daily living (ADL’s), personal cares, and hygiene. E. The observation of the provision of SN services on 8/27/25 at 10:30 AM by Staff-DD to Patient 1 revealed the SN failed to perform hand hygiene after completing a lower body assessment and prior to obtaining toothettes (sponge toothbrush) and completing oral cares to the patient. F. The observation of the provision of morning cares on 8/26/25 at 8:20 AM by the inpatient certified nursing assistant (CNA) (Staff- R) to Patient 4 revealed the CNA failed to perform hand hygiene after completing a partial bath and toilet hygiene and prior to leaving the patient room, and prior to entering the community kitchen area to obtain a cup of coffee for Patient 4 from the community coffee machine. G. During an interview on 9/2/25 at 1:30 PM, the Inpatient Executive Director and the Inpatient Clinical Manager confirmed hospice staff failed to follow the hospice’s policies for proper hand hygiene when providing cares to Patient 1 and 4.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to update the Hospice Aide (HA) Plan of Care (POC) with patient specific interventions and needs to ensure the hospice aide has all necessary information to provide care and services for 3 of 16 patients who receive HA services from the agency (Patient’s 11, 16, and 19). The total sample size was 28. The Census was 77 (including 11 inpatient hospice patients and 66 branch patients). Findings are: A. Review of the agency policy and procedure titled, 33.37 Aide and Homemaker Plan of Care, revised 8/10/22 revealed: 1. The Aide and Homemaker Plan of Care (POC) is a means to assess, plan, implement, evaluate, and coordinate all aspects of the patient’s care give by the aide.2. The POC can be individualized to include special orders, requests, frequencies, and assistance needed.3. The POC was to be reviewed and updated at the beginning of every certification period and as needed with patient change in condition.4. Review and or changes to the POC are to be documented in the patient’s medical record. 5. Was to be reviewed by the HA prior to each visit. B. Review of Patient 11’s clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 8/20/25 through 11/17/25 included: a. Orders for hospice aide (HA) one time per week for one week, then two times per week for twelve weeks, the one time a week for one week to provide assistance with personal care, hygiene, and activities of daily living (ADL’s). b. The patient is on 5 liters per minute of oxygen. c. The patient becomes dyspneic (short of breath- SOB) with minimal exertion. d. Needs fall precautions. e. Needs seizure precautions. 2. A Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/27/25 revealed the patient has frequent falls, gets very SOB with any activity, can have behavioral and aggression with staff. 3. The Aide Care Plan Report (the POC) developed 8/20/25 did not include patient specific interventions or instructions for the HA to utilize for SOB, fall precautions, seizure precautions, oxygen use, and behavior management. B Review of Patient 16’s clinical record revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 5/20/25 through 8/17/25 and 8/18/25 through 10/16/25 included orders for HA two times per week to provide assistance with personal care, hygiene, and ADL’s.2.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 5/28/25 revealed the patient had buttock/coccyx wounds with treatments in place. 3.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 8/6/25 revealed the patient had buttock/coccyx wounds with treatments in place, wounds to bilateral heels, left lateral heel, and leg, heel protectors, floating heels to off-load feet, and a request for the caregiver to administer pain medication before bath, cares, or repositioning. 4.The Aide Care Plan Report (the POC) developed 2/20/25 did not include updated patient specific interventions or instructions for the HA to utilize for buttock/coccyx wounds, wounds to bilateral heels, left lateral heel, and leg, heel protectors, floating heels to off-load feet, and to verify the caregiver administered pain medication before bath, cares, or repositioning. C. Review of Patient 19’s clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 7/22/24 through 10/19/24 included orders for HA one time a week for one week, the two times a week for twelve weeks provide assistance with personal care, hygiene, and ADL’s.2.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 10/2/24 revealed the patient has a nephrostomy tube (a thin catheter inserted directly into the kidney that drains urine into a bag) to his right side, a suprapubic catheter (a urinary catheter that is inserted directly into the bladder through a small incision in the lower abdomen to drain urine), unable to bear weight, a hoyer lift for transfers, and use of oxygen due to SOB with exertion. 3. The Aide Care Plan Report (the POC) developed 7/22/24 did not include updated patient specific interventions or instructions for the HA to utilize for the nephrostomy tube to his right side, a suprapubic catheter, inability to bear weight, a hoyer lift for transfers, and use of oxygen due to SOB with exertion. D. During an interview on 9/9/25 at 3:15 PM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed the HA POC for Patient’s 11, 16, and 19 were not updated with patient specific interventions and needs to ensure the hospice aide has all necessary information to provide care and services to the agency’s hospice patients.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure a Registered Nurse (RN) conducted an on-site visit at least every 14 days to the patient’s home, for 4 of 16 patients reviewed (Patient 5, 16, 18, and 19), who received hospice aide (HA) services, to ensure the HA services meet the needs of the patient. The total sample size was 28. The census was 77 (including 11 inpatient hospice patients and 66 branch patients). Findings are: A. Review of the agency policy and procedure titled 33.37 Aide and Homemaker Plan of Care, last revised 8/10/22, revealed the RN was to visit the patient’s residence to supervise the aides at least every 14 days when aide services are provided. The visit was to include an assessment of the aide services, with or without the aide present. B. Review of Patient 5’s clinical records revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 6/2/25 through 7/31/25 and 8/1/25 through 9/29/25 included orders for HA services two times per week for assistance with personal cares, hygiene, and activities of daily living (ADL’s). 2.There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 6/16/25 and 6/18/25 through 9/2/25. C Review of Patient 16’s clinical records revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 5/20/25 through 8/17/25 and 8/18/25 through 10/16/25 included orders for HA services two times per week for assistance with personal cares, hygiene, and ADL’s. 2. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 9/10/25. D. Review of Patient 18’s clinical records revealed:1.The Hospice Certification and Plan of Care for the certification period of 5/8/25 through 8/5/25 included orders for HA one time per week for thirteen weeks for assistance with personal cares, hygiene, and ADL’s. 2. The Hospice Recertification and Plan of Care Update for the certification periods of 8/6/25 through 11/3/25 included orders for HA services one time per week for assistance with personal cares, hygiene, and ADL’s. 3. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 7/1/25 and 7/3/25 through 7/29/25. E. Review of Patient 19’s clinical records revealed:1. The Hospice Certification and Plan of Care for the certification period of 7/22/24 through 10/19/24 included orders for HA one time per week one week then 2 times a week for twelve weeks for assistance with personal cares, hygiene, and ADL’s. 2. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 7/24/24 through 8/8/24 and 8/16/24 through 9/24/24. F. During an interview on 9/9/25 at 3:15 PM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed a RN did conducted an on-site visit at least every 14 days to the home of Patient 5, 16, 18, and 19 to ensure the HA services meet the needs of the patient.”

“Based on review of inpatient hospice policies and procedures, material safety data sheet (MSDS), inpatient hospice observations, and staff interviews, the inpatient hospice failed to ensure hazardous chemicals were stored in accordance with the MSDS and the inpatient hospice policies and procedures. The inpatient census was 11. Findings are:A. Review of the inpatient hospice policy titled Hazard Communication, revised 1/11/23, revealed the inpatient hospice is responsible for the proper use, storage and disposal of hazardous chemicals per the chemicals MSDS.B. Review of the inpatient hospice MSDS titled Virex TB Ready-To-Use-Disinfectant Cleaner, revised 7/31/24, revealed this disinfectant cleaner must be stored in a well-ventilated place and avoid inhalation and eye and skin exposure.C. Observation of the inpatient hospice dirty oxygen storage closet on 8/25/25 at 1:45 PM the following were identified:1. Two spray bottles labeled Virex Tb Redi-To-Use Disinfectant, one bottle containing 1/8th of the disinfectant and the second bottle containing 1/4th of the disinfectant.D. During staff interview on 8/27/25 at 11:30 AM, the Clinical Nurse Manager (CNM) revealed they were unaware of the two spray bottles containing the Virex TB Redi-To-Use Disinfectant located in the dirty oxygen storage closet. The CNM confirmed it is the expectation that all chemicals are locked up to ensure resident safety.”

“Based on review of inpatient hospice policies and procedures, inpatient hospice observations, and staff interviews, the inpatient hospice failed to have a process for storage and removal of used empty aluminum cans away from the inpatient hospice catering kitchen dry goods pantry. This failed practice had the potential to affect all 11 patients on census at the inpatient hospice as well as any families, inpatient hospice staff and volunteers. Findings are:A. Review of the undated inpatient hospice policy titled Dietary Services, revealed the inpatient hospice is responsible to procure, store, prepare, distribute, and serve all food under sanitary conditions.B. Review of the undated inpatient hospice policy titled Utilization of Family and Common Area Kitchen Equipment, revealed inpatient hospice employees will oversee the kitchen for proper clean-up following food preparation.C. During observation of the inpatient hospice catering kitchen on 8/25/25 at 10:45 AM with the Clinical Nurse Manager, the following were identified on the floor of the pantry:1. Three large, clear trash bags containing used empty aluminum cans.D. During staff interview on 9/2/25 at 1:30 PM, the Executive Director revealed the three bags were placed there to be recycled at a later date. The Executive Director confirmed a process did not exist within the inpatient hospice policies for the storage and removal of recyclables.”

“Based on review of hospice house policies and procedures, facility observations, and staff interviews, the inpatient hospice failed to store food at the proper temperature in the catering kitchen. This failed practice had the potential to affect all 11 patients on census at the hospice house as well as any families, facility staff and volunteers utilizing the catering kitchen. Findings are: A. Review of the undated facility policy titled Dietary Services, revealed the inpatient hospice is responsible to procure, store, prepare, distribute, and serve all food under sanitary conditions and in accordance with the Food Code Neb. Rev. Stat. 81-2,244.01.B. Review of the undated inpatient hospice policy titled Utilization of Family and Common Area Kitchen Equipment, revealed hospice employees will oversee the kitchen and anyone using the kitchen is responsible for proper clean-up following food preparation.C. During observation of the inpatient hospice catering kitchen on 8/25/25 at 10:45 AM with the Clinical Nurse Manager, the following were identified:1. A bowl containing 12 packets of butter and 15 packets of whipped margarine, all of which were labeled individually with instructions to refrigerate, were at room temperature. D. During staff interview on 9/2/25 at 1:30 PM, the Executive Director confirmed the inpatient hospice failed to refrigerate the packets of butter and whipped margarine.”

“Based on record review, policy and procedure review, and staff interview, the in-patient hospice failed to ensure intravenous (IV) medications were administered to 1 of 2 patients sampled, who received IV medications (Patient 3), in accordance with the requirements of Nebraska State Law at Title 175 NAC Chapter 16-006.11 Administration of Medications: The hospice must establish and implement policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards; and at 16-002: Five rights means getting the right drug to the right recipient in the right dosage by the right route at the right time. The total sample size 4. The census was 86 (16 in-patient and 70 multiple location patients). Findings are: A. Review of the agency policy and procedure titled, Medications, revised 2/2024, revealed medications were to be administered according to the five rights (a standards of practice which require the person administering medication to verify the right patient, the right drug, the right time, the right dose, and the right route prior to administering a medication). B. Review of Patient 3’s clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 2/9/24 through 5/8/24 included orders for: a. Amiodarone 450 milligrams (mg) / 250 milliliters (ml) (1.8 mg/ml) in dextrose 5 percent (%) intravenous solutions with instructions to infuse 360 mg/200 ml continuous infusion via the right intrajugular (IJ) central venous catheter (CVC) (is a long, flexible tube inserted into a vein in your neck, that leads to your vena cava, a large vein that empties into your heart) using the blue pigtail (a port on the catheter) at 33.3 ml/hour for heart rhythm. b. Lidocaine hydrochloride 20 mg/ml (2%) injection solution with instructions to give lidocaine 2 grams/250 ml continuous infusion through the right IJ CVC using the brown pigtail at 4.5 ml/hour for ventricular tachycardia (rapid irregular heart beat). 2. An untitled medication record sheet with information to nurses regarding the amiodarone. The notation informed the nurse that the amiodarone was set at a high flow rate and the (medication) bag would need to be replaced every shift as it administers over a 5- to- 6 hour time period. 3. A nurses note dated 2/10/24 at 03:20 AM. The Registered Nurse (RN) documented that a new lidocaine bag was hung (placed on the infusion pump used to administer the IV medication) at 03:05 AM. The same RN documented at 07:45 AM, when checking IVs with the day shift nurse it was discovered duplicate doses of lidocaine were being administered to the patient through both ports instead of one port with lidocaine and one port with amiodarone. C. During an interview on 2/26/24 at 2:45 PM, RN-E: 1. Was able to verbalize knowledge of the 5 rights of medication administration. 2. Confirmed [gender] did not follow the 5 rights of medication administration to ensure the right medication (amiodarone) was administered to Patient 3 on 2/10/24 at 3:05 AM. 3. Confirmed the wrong medication was administered to the patient at 3:05 AM on 2/10/24. D. During an interview on 2/15/24 at 2:45 PM, the in-patient Clinical Manager confirmed RN-E failed to follow the agency policy and procedure to follow the 5 rights of medication administration and failed to administer the correct medication to Patient 3 at 3:05 AM on 2/10/24.”