Trine Hospice Care LLC

“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. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 1: Agency Policy: Infection Control - Hand Hygiene Policy Number PC.I25 not dated, stated in part, “When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.” HOME VISIT 1: During the home visit (Clinical Record 3) on 02/04/2025 with the Hospice Aide (HA) (Personnel Record 9), the HA was observed to wash the hands with soap and water, turn off the water with wet hands, and then dry the hands with paper towels. During an interview on 05/22/2024, the Alternate Director of Patient Care Services agreed the staff did not follow the hand hygiene policy.”

“It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed the agency did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, under the direction of a physician. CLINICAL RECORD 2: The patient’s date of election was 11/26/2024. The POC/IDG [Plan of Care/Interdisciplinary Group] reviews dated 11/25/2024, 11/27/2024, 12/11/2024, 12/25/2024, 01/08/2025, and 01/22/2025 documented, “Medical Social Worker/Licensed Social Worker visit frequency initial visit for assessment and evaluation of the patient’s psychosocial needs within 5 days, then once a month, 3 visits as needed and re-certification to provide psychosocial support to the patient and family.” There was no documented evidence social work visits were made 1 x monthly between 12/01/2024 and 12/31/2024. A Communication Log entry for 01/31/2024 by PRR#2 documented, “Called patient to inform SW is on his way to see the patient but patient has declined and wants to reschedule the visit to another time.” There were no other attempts between 01/01/2025 and 01/31/2025 to visit. During a joint record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that there was no documented evidence that social work services were provided during the times identified.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical record review with hospice aide services revealed that the agency did not ensure that the registered nurse prepared the written patient care instructions for a hospice aide. CLINICAL RECORD 4: The POC/IDG [Plan of Care/Interdisciplinary Group] review documents dated 04/19/2024 and 04/24/2024 documented, “Hospice Aide: 2 visits per week for ADLs assistance and personal care” to start 04/19/2024. The record lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide. During a joint record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that the records lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical record review with hospice aide services revealed that the agency did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group. CLINICAL RECORD 4: The POC/IDG [Plan of Care/Interdisciplinary Group] Review documents dated 04/19/2024 and 04/24/2024 documented “Hospice Aide: 2 visits per week for ADLs assistance and personal care” to start 04/19/2024. The record lacked hospice aide visit documentation from 04/19/2024 to 04/24/2024. During a joint clinical record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that the records lacked evidence of documented hospice aide visits as ordered by the Interdisciplinary Group.”

“It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 1: The date of the HA [Hospice Aide] Assignment was 11/26/2024. The HA [Hospice Aide] Flow Sheets dated 12/05/2024 and 12/12/2024 documented, “Applied Nystatin on skin irritation.” The HA Assignment/Plan of Care did not include “apply Nystatin on skin irritation.” CLINICAL RECORD 3: The date of the HA [Hospice Aide] Assignment was 11/14/2024. The HA [Hospice Aide] Flow Sheet dated 11/29/2024 documented, “Assisted patient with her nebulizer as per request.” The HA Assignment/Plan of Care did not include “assist patient with nebulizer as per request.” During a joint clinical record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that the hospice aide provided services that were not included in the plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with hospice aide services revealed that the agency did not ensure the hospice aide notified the registered nurse of care provided outside of the HA assignment. CLINICAL RECORD 1: The date of the Hospice Aide Care Plan was 11/26/2024. The HA [Hospice Aide] Flow Sheet dated 11/27/2024 documented, “MISSED VISIT Husband Ken took over the care.” The HA [Hospice Aide] Flow Sheets dated 12/05/2024 and 12/12/2024 documented, “Applied Nystatin on skin irritation.” The HA Assignment did not include “apply Nystatin on skin irritation.” The documentation lacked evidence of a notification to the registered nurse of the application of Nystatin to the skin irritation. CLINICAL RECORD 3: The date of the HA [Hospice Aide] Assignment was 11/14/2024. The HA [Hospice Aide] Flow Sheet dated 11/29/2024 documented, “Assisted patient with her nebulizer as per request.” The HA Assignment did not include “Assisted patient with her nebulizer as per request. The documentation lacked evidence of a notification to the registered nurse that the HA had assisted patient with their nebulizer. During a joint clinical record review and interview on 02/06/2025, the Alternate Director of Patient Care services confirmed that the hospice aide documentation lacked evidence of a notification to the registered nurse when care was provided that was not on the HA assignment/Plan of Care.”