Holy Name Hospice

“Observed in Record Review. In 1 of 4 home visits conducted, it was noted the organization failed to assess potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example during medication reconciliation of HHRRHV#3, the hospice nurse surveyor noted that the hospice nurse was performing medication reconciliation by showing the medication pill box she had filled for the prior and subsequent week. This finding was discussed and validated by the Hospice Director who was present during the visit.”

“Observed in Record Review. In 14 of 14 active patient’s records, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. Upon review of the records, multiple PRN pain medications ordered were to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example; Acetaminophen 650 mg 1 tablet PO PRN for mild pain and Morphine Sulfate 100mg/5ml every 3 hours for pain.This was noted on all records of HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, HOSRRNHV#10, HOSRRNHV#11, HOSRRNHV#12, HOSRRNHV#13, and HOSRRNHV#14. This finding was discussed and validated by the hospice management team.”

“Observed in Record Review. In 2 of 8 active patient records with hospice aide services, it was noted the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example, in review of record HOSRRNHV#5, the hospice plan of care ordered hospice aide visits three times weekly, but only one visit was completed on the 5th week of benefit period#3. Further review, no missed visit report documented. In review of record HOSRRNHV#6 revealed only 2 of the 3 scheduled hospice aide visits, as per plan of care, were completed during the last week of benefit period three (3) . No documentation was found indicating the reason for the missed visit. This finding was discussed and validated by the hospice management team.”

“Observed in Medication Management Tracer. it was noted the organization failed to follow procedures for the control and accountability of all medications within the hospice facility as required by its policy (MM1.0.0.09z). For example during the inpatient hospice visit, the clinical nurse described the process for counting controlled substances, which involves both incoming and outgoing staff verifying the count and signing the paper controlled substances sheet.However, a review of the documentation revealed one instance in September 2025 where clinician signatures were missing. There was no documentation provided to explain the absence of these signatures. This finding was discussed and validated by the hospice management team.”

“Observed in Building Tour. In the basement clean linen room, observed a sprinkler head compromised because the escutcheon plate, partially covered with sheetrock plaster. This observation was confirmed by the facility’s manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Observed in Building Tour. In 2 of 3 above ceiling checks, Observed on the 1st and 2nd floor patient areas near the elevator, piping for the approved automatic sprinkler systems was supporting electrical wiring. This observation was reviewed with the facility’s manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.”

“Observed in Building Tour. The bulk oxygen supply shutoff valave was not labelled. This observation was confirmed by the facility’s manager. Observed in Building Tour. In 6 of 10 electrical panel checks, During the building tour of the Hospice Inpatient unit, the hospice surveyor observed unlabeled breakers set to the on position in the following electrical panels:1. Basement near UPS, Panel CR-DP breaker# 6 thru 202. Basement medical gas room, panel CRB-2 breakers # 6 thru 223. 2nd floor electrical closet panel UPS-2, breaker 5-18 - panel N2, breakers 32-42 & 27- 35 - panel LS-2, breakers 6-22 - panel CR-2, breakers 7-42These observations were verified by the facility manager. Observed in Document Review. The main drain testing documentation did not record the time for the system to return to static pressure. This observation waws confirmed by the facility’s manager.”