The Hospice at Lourdes

“Based on clinical record review and staff interviews, it was determined for 1 of 18 patients (patient #2) the hospice failed to ensure that the interdisciplinary comprehensive assessment was complete and identified all of the patient’s needs. Home visitPatient #2 was admitted to the hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer. The patient had been admitted to the hospital with an abdominal abscess on 05/30/25, had an Aspira drain (a thin, soft tube surgically placed into abdomen to help drain excess fluid) placed on 06/10/25, and was discharged home with a hospice referral on 06/12/25. The hospice interdisciplinary group failed to complete a comprehensive assessment as follows:Aspira drain site and care The Interdisciplinary Group (IDG)/Care Plan dated 06/13/25 included:Problem: Drains/Wound Care- Aspira Drain left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by hospice RN (HN) or caregiver [name of patient’s parent identified]. Intervention: Abdominal drain dressing change:- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25 the hospice nurse (HN) visited the patient for the initial assessment and documented abdomen round, distended, upper quadrants tender upon palpation, Aspira drain noted on left upper abdomen, dressing clean, dry and intact (CDI), caregiver (CG) reports Aspira drain was accessed twice today, 1,000cc clear yellow fluid drained at 0830, 700 cc clear yellow fluid drained (time not noted). CG verbally describes process of draining Aspira drain, is competent in accessing drain, drain can be accessed by Hospice RN or CG, in AM and PM PRN, no more than 1,000cc taken off at a time, CG notified of parameters, CG and patient are receptive with good understanding. (CG later identified as the patient’s significant other by HN).There was no evidence the HN assessed the Aspira drain site (aside from documenting the dressing being clean, dry, and intact).The visit note concluded: Next hospice nurse visit Saturday post-admission follow up, comfort pack education, comfort, pain, safety, Aspira drain.On 06/14/25 the HN visited and documented Gastrointestinal Issues: abdominal pain, ascites; bowel sounds were present throughout; and the patient had some abdominal distension and tenderness. There was no evidence the HN assessed the Aspira drain site, which caregiver was performing care, or the caregiver’s ability to perform the care.On 06/17/25 the HN visited and documented patient had an Aspira drain the significant other/caregiver reported accessing three times per day as they were doing in the hospital, and the nurse reviewed with them to access no more than two times per day as ordered. There was no evidence the nurse assessed the site or the caregiver’s ability to perform the site care.On 08/07/25 at 12:14 p.m., the surveyor interviewed the HN (employee D) who visited 06/14/25. They stated assessment of the Aspira drain site and care was not completed as the demonstration had been completed the day prior during the admission visit.On 08/07/25, at 12:25 p.m., the surveyor interviewed the HN (employee C) who performed the initial visit. They said the CG that gave the verbal description of the Aspira drain procedure was the patient’s significant other, and that the HN’s plan/intent was for the HN the following day to follow up on Aspira drain, including to observe the caregiver perform the care, which would also include observing the site. Upon review of their note, they acknowledged the plan was not clear.Hoyer lift (mechanical lift to assist transferring a bed-bound patient)On 06/14/25 the HN visited and documented: Ambulation assist: non-ambulatory, Transfer assist: maximum assist, one person, two person. Comments: Pt was tearful because only his adult (child) can get him up and help him to the restroom. Patient was asking about alternatives to assist with moving. Writer explained they don’t utilize lifts or have any type of machines to help lift patients like they were requesting.On 06/17/25 the hospice nurse and social worker visited together. The HN documented the significant other was upset throughout the visit and under the impression the hospice supplied a Hoyer lift, physical therapy, and ramp and that they were told this in the hospital. The social worker and nurse apologized for the miscommunication and provided support by listening and validating feelings. The nurse documented the significant other obtained a Hoyer lift, paying out of pocket, and bought a scooter. The patient was weak, unable to ambulate. The patient’s adult child reported the patient could transfer from bed to wheelchair or bedside commode by holding onto them and stomping their feet due to uncontrolled gait. The patient agreed to transport chair, walker, gait belt, shower chair, and gel mattress.There was no evidence the HN and social worker assessed safety of the Hoyer lift and scooter, or communicated this with the Interdisciplinary Group (IDG).The Hospice Admission IDG Plan of Care was effective 06/13/25 and finalized 06/16/25. There was no evidence the IDG considered all information gathered during the during the initial assessments. The IDG failed to complete the comprehensive assessment including assessing status of the drain site, identification of caregivers performing Aspira drain and site care, caregivers’ ability to perform care, and assessment of whether a Hoyer lift should be part of this patient’s individualized plan of care.”

“Based on a review of patient care records, and interviews with agency staff, it was determined 1 of 18 patients (patient # 2), the hospice nurse Hospice IDG failed to assess for changes in the patient’s condition to identify and meet their needs. Evidence as follows:Home visitPatient #2 was admitted to the hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.On 06/20/25, the HN visited the patient and documented a new wound was noted to patient’s coccyx. The HN documented that it was a superficial wound, the wound was cleansed with wound cleanser, patted dry, small amount of calmoseptine (a protective skin care barrier) applied, and covered with a foam border dressing. Dressing to be changed every 3 days and as needed for soiling. The dressing changes were to be completed by HN or [name of significant other] (SO). There was no evidence in the record that the patient’s SO was assessed to be proficient in providing wound care to the coccyx.On 06/22/25, the HN visited to assess the caregiver‘s ability to perform drainage and site care of the Aspira abdominal drain (a thin, soft tube surgically placed into abdomen to help drain excess fluid). The CG observed was patient’s 16-year-old child who was not identified in the IDG Care Plan as individual to perform.The HN documented the CG had items needed nearby on the overbed table and opened supplies needed. They proceeded to remove the old dressing and then applied sterile gloves and using sterile technique set up the drainage system, cleaned the tubing and accessed it. The fluid was allowed to flow until the bag had 1,000 cc which was then dumped into the toilet and the garbage was disposed of in a garbage bag.The HN failed to assess the Aspira site cleansing, redressing, or wound care to patient’s coccyx during the visit.On 06/27/25, the HN visited and documented: - insertion site assessed and “no sterile dressing present; tube was simply taped to the abdomen” - [name of significant other] stated the dressing “kept falling off” so they left it off - demonstrated application of the sterile dressing to site for good skin adhesion - [significant other] reported the dressing from the sterile dressing kit “didn’t look familiar”It was unclear what dressing the caregivers had been using to cover the Aspira site.There was no documentation that the coccyx wound or proficiency providing wound care was assessed during the visit. On 07/15/25, the HN visited and documented assessment of the Aspira drain site was completed as the patient and significant other (SO) reported the patient was having pain at the site. The HN documented: - skin above tunneled area is red - writer applied some pressure to area and scant amount of light yellow/greenish drainage came out- HN spoke to the hospice Medical Director who stated Aspira drain needed to be removed as fluid was not being drained any longer and they did not believe it was an infection at that timeOn 07/22/25, the Aspira drain was removed by Interventional Radiology.On 07/23/25, the HN documented the coccyx wound was assessed, stage 2 pressure ulcer noted, wound care completed, applied sacrum foam border dressing. There was no evidence in the record that wound care to the coccyx was demonstrated by SO. The HN further documented that the SO stated the patient was feeling warm/fever yesterday after the drain removal and gave the patient acetaminophen. On 07/31/25, the HN visited and documented, “patient complains of abdominal pain and stomach feeling extremely warm,” and “I feel like I have an infection.” The HN contacted the hospice Medical Director who ordered Bactrim DS (antibiotic), one tab twice daily for 10 days. Diagnosis listed in Bactrim order “for spontaneous peritonitis” (an infection within the abdominal cavity).On 08/05/25 at 2:00 p.m., the surveyor interviewed the caregiver who stated neither they, nor any caregiver, received training on the procedure to change the coccyx dressing or received any Calmoseptine.On 08/07/25 at 1:00 p.m., the surveyor interviewed the HN (employee F) that performed the demonstration of the Aspira drain and site care on 06/22/25. They stated they discussed concerns with the Case Manager, and RN Manager B re: caregiver competency and order change Friday, (06/20/25). The decision was made at that time for observation/demonstration to occur on 06/22/25.During the interview the surveyor asked the HN if the cleansing and redressing of the site had been observed. The HN stated yes, they cleansed the site with an alcohol prep pad and covered with an ABD (thick abdominal pad dressing) and tape and did not use a sterile dressing kit. The HN stated they did not use a kit, were not sure if the patient had any sterile dressing kits on hand, and did not know where the ABD came from.On 08/07/25 at 2:30 p.m., the surveyors interviewed the Palliative Physician who stated they prefer nursing does the procedure (to drain and perform dressing change of the Aspira) but the family can do it after they demonstrate they can do it.When asked if the inconsistent care of and lack of complete demonstration could have led to infection, the physician replied it could have, however it could have also happened regardless in an immunocompromised individual with advanced malignancy.A review of the record revealed the first assessment of the drain site and care demonstration (using dressing materials not found in the physician’s order) occurred 9 days after admission, and a demonstration of the procedures using the correct ordered dressing materials had never occurred.The hospice/IDG failed to:- assess and plan for the specific caregivers involved in providing care pf the Aspira drain and wound care to coccyx- assess the CG to ensure care was being performed correctlyFailure to ensure that comprehensive assessments are updated and reflect changes in the current status of the patient has the potential for unmet patient needs and possible negative outcomes for the entire patient population.”

“Based on clinical record review and staff interviews, it was determined that the hospice failed to ensure that the interdisciplinary group establish an individualized written plan of care specific to the patient and family’s needs identified in the comprehensive assessment for 2 of 18 patients (patients #2 and 3).Evidence as follows: Home visit1. Patient #2 was admitted to the Hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.The Hospice Admission Interdisciplinary Group Meeting/Care Plan dated 06/13/25 included: - Aspira Drain (a thin, soft tube (catheter) that a doctor surgically places into abdomen to help drain this excess fluid) location left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by Hospice RN or caregiver (patient’s parent). - Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25 the hospice nurse (HN) visited the patient for the initial assessment and documented the caregiver (CG) verbally described process of draining Aspira drain, was competent in accessing the drain, may be accessed by HN or CG. The description of the verbal competency documented stopped after the step to drain the fluid and did not include how the CG described the dressing change and supplies. On 06/17/25, the HN Case Manager visited and documented [significant other] reported they are accessing 3 times per day as they were doing in the hospital (rather that twice each day per the plan of care). The HN failed to collaborate with the physician on both 06/13/25 and 06/17/25 to update the Interdisciplinary Group Meeting/Care Plan to include the patient’s significant other who was not originally identified in the plan of care to perform the task or address frequency of dressing change.On 06/22/25, the HN visited for “follow-up education and to watch a return demonstration.” The HN documented the CG observed was the patient’s 16-year-old daughter, not listed in the physician’s orders to perform the procedure.On 06/27/25, a HN visited and documented: - insertion site assessed and “no sterile dressing present; tube was simply taped to the abdomen” - [significant other] stated the dressing “kept falling off” so they left it off - demonstrated how to apply Aspira dressing for good skin adhesion - [significant other] reported the dressing from the sterile dressing kit “didn’t look familiar”It was unclear what dressing the caregivers had been using to cover the site. On 07/10/25, the HN Case Manager submitted an order for 2 boxes of 10 ABD pads. The plan of care did not include the use of ABD pads.On 08/07/25, at 12:25 p.m., the surveyor interviewed the HN (employee C) who performed the initial visit. They said the CG that gave the verbal description of the Aspira drain procedure was the patient’s significant other, and not the CG specified in the Plan of Care. The HN could not recall the rest of the verbal demonstration of competency including what dressing materials would have been used.On 08/07/25 at 1 p.m., the surveyor interviewed the HN (employee F) that visited 06/22/25 for the redemonstration who observed the patient’s 16-year -old child and stated they had watched the rest of the dressing procedure and described: - They cleansed the site with an alcohol prep and then covered the site with an ABD (thick abdominal pad) and taped it. - They did not use a sterile dressing kit. - The Nurse Manager told us we could substitute a PICC (peripherally inserted central catheter) line dressing kit if the sterile dressing kits were unavailable, but neither of the kits had been used during the observed procedure.On 08/07/25 at 2:30 p.m., the surveyors interviewed the Palliative Physician who stated: - if there was no sterile dressing kit available, they would prefer they go and get one (sterile dressing kit) - they would prefer the procedure was scheduled so the 16-year-old child didn’t have to do itOn 08/07/25 at 3:40 p.m., the surveyor interviewed RN Manager B who stated, they were unable to get the sterile dressing kits but learned today they were now available. They were substituting the PICC line dressing kits and using a larger Tegaderm (thin, transparent, and breathable “second skin” for wounds) to cover.The Hospice failed to ensure the Hospice nurses followed the interdisciplinary Group meeting/Care Plan as follows: - ensure the ordered caregiver performed the task and collaborate with the physician if there was a change - ensure the sterile procedure ordered included detailed steps and identified specific materials necessary to perform consistent, sterile, dressing changes - identify when the Interdisciplinary Group Meeting/Care Plan was not followed and update as needed Home VisitPatient #3 was admitted to the hospice on 03/05/25 with a terminal diagnosis of malignant neoplasm of lower third of the esophagus.On 08/05/25 at 12:00 p.m., the surveyor performed an observational home visit with the hospice nurse.The Interdisciplinary Group Meeting/Care Plan dated 07/30/25 included orders for enteral tube site care as follows:To be performed twice a week by hospice nurse, cleanse surrounding skin with normal saline, pat dry, apply anti-fungal, apply 4x4 split gauze around tube, secure with tape.During the visit, the surveyor observed the hospice nurse perform enteral site care. The hospice nurse: - removed the old dressing, which was secured with Tegaderm (transparent adhesive dressing cover) - cleansed the surrounding skin with normal saline - patted the area dry - applied anti-fungal powder - applied 4x4 split gauze around tube - applied a Tegaderm over the split gauze and tube siteOn 08/06/2025 at 12:45 p.m., the surveyor interviewed via phone the hospice nurse that was observed performed the dressing change. They stated they used the Tegaderm to secure the gauze instead of the ordered tape because the patient preferred it and it was more secure.The hospice nurse failed to obtain an order to use Tegaderm instead of tape and update the Interdisciplinary Group Meeting/Care Plan.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the registered nurse managers who acknowledged the findings and provided no additional information. Home visit1. Patient #2 was admitted to the Hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.The Hospice Admission Interdisciplinary Group (IDG)/Care Plan dated 06/13/25 included:Problem: Drains/Wound Care- Aspira Drain left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by hospice RN (HN) or caregiver [name of patient’s parent identified]. Intervention: Abdomnl drain dressing change:- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25 the HN visited the patient for the initial assessment and documented the caregiver (caregiver not specified) verbally described process of draining Aspira drain, was competent in accessing the drain, may be accessed by HN or CG (caregiver). The documentation did not include verbal competency of the caregiver’s ability to perform dressing changes at the care planned frequency or using a sterile dressing kit.On 06/17/25, the HN Case Manager visited and documented the patient’s significant other (not caregiver specified on the Care Plan) reported they were accessing 3 times per day. On 06/22/25, the HN visited for “follow-up education and to watch a return demonstration.” The HN documented the CG observed was the patient’s 16-year-old child who also was not listed in the physician’s orders to perform the procedure.The agency failed to ensure the established care plan was followed on 06/13/2025, 06/17/2025 and 06/22/2025 when the patient’s significant other and/ or child (not the persons identified on the Care Plan) were the caregiver(s) providing care to the patient’s Aspira drain when the HN wasn’t present.On 08/07/25, at 12:25 p.m., the surveyor interviewed the HN (employee C) who performed the initial visit. They said the CG that gave the verbal description of the Aspira drain procedure was the patient’s significant other, and not the CG specified in the Plan of Care. On 08/07/25 at 1 p.m., the surveyor interviewed the HN (employee F) that visited 06/22/25 for the demonstration of care provided by the patient’s 16-year-old child. The HN stated they watched the child perform the rest of the dressing procedure and that they did not use a sterile dressing kit. Employee F stated sterile dressing kits were not available in the home during this visit and the Nurse Manager was aware. The HN also stated the Nurse Manager said they could substitute a PICC (peripherally inserted central catheter) line dressing kit if the Apsira sterile dressing kits were unavailable, but neither of the kits had been used during the observed procedure.On 08/07/25 at 2:30 p.m., the surveyors interviewed the Palliative Physician who stated they would prefer care of the Aspira drain was scheduled so the 16-year-old child didn’t have to do it.On 08/07/25 at 3:40 p.m., the surveyor interviewed RN Manager B who stated they were unable to get the sterile dressing kits, they were substituting the PICC line dressing kits and using a larger Tegaderm (thin, transparent, and breathable “second skin” for wounds) to cover.The agency failed to ensure the hospice nurses followed the IDG/Care Plan as follows: - ensure the ordered caregiver performed the task - ensure the sterile procedure ordered included detailed steps and identified specific materials necessary to perform consistent, sterile, dressing changes - identify when the IDG/Care Plan was not followedHome Visit2. Patient #3 was admitted to the hospice on 03/05/25 with a terminal diagnosis of malignant neoplasm (cancer) of lower third of the esophagus.The IDG/Care Plan dated 07/30/25 included orders for enteral tube site care as follows:To be performed twice a week by hospice nurse, cleanse surrounding skin with normal saline, pat dry, apply anti-fungal, apply 4x4 split gauze around tube, secure with tape.On 08/05/25 at 12:00 p.m., the surveyor performed an observational home visit with the hospice nurse. During the visit, the surveyor observed the hospice nurse perform enteral site care. The hospice nurse: - removed the old dressing, which was secured with Tegaderm (transparent adhesive dressing cover) - cleansed the surrounding skin with normal saline - patted the area dry - applied anti-fungal powder - applied 4x4 split gauze around tube - applied a Tegaderm over the split gauze and tube siteOn 08/06/2025 at 12:45 p.m., the surveyor interviewed the hospice nurse that was observed performed the dressing change. They stated they used the Tegaderm to secure the gauze instead of the ordered tape because the patient preferred it and it was more secure.The hospice nurse failed to follow the IDG/Care Plan, or obtain an order and update the plan, to use Tegaderm instead of tape.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the RN Managers who acknowledged the findings and provided no additional information. Home visit1. Patient #2 was admitted to the Hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.The Hospice Admission Interdisciplinary Group (IDG)/Care Plan dated 06/13/25 included:Problem: Drains/Wound Care- Aspira Drain left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by hospice RN (HN) or caregiver [name of patient’s parent identified]. Intervention: Abdominal drain dressing change:- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25 the HN visited the patient for the initial assessment and documented the caregiver (caregiver not specified) verbally described process of draining Aspira drain, was competent in accessing the drain, may be accessed by HN or CG (caregiver). The documentation did not include verbal competency of the caregiver’s ability to perform dressing changes at the care planned frequency or using a sterile dressing kit.On 06/17/25, the HN Case Manager visited and documented the patient’s significant other (not caregiver specified on the Care Plan) reported they were accessing 3 times per day. On 06/22/25, the HN visited for “follow-up education and to watch a return demonstration.” The HN documented the CG observed was the patient’s 16-year-old child who also was not listed in the physician’s orders to perform the procedure.The agency failed to ensure the established care plan was followed on 06/13/2025, 06/17/2025 and 06/22/2025 when the patient’s significant other and/ or child (not the persons identified on the Care Plan) were the caregiver(s) providing care to the patient’s Aspira drain when the HN wasn’t present.On 08/07/25, at 12:25 p.m., the surveyor interviewed the HN (employee C) who performed the initial visit. They said the CG that gave the verbal description of the Aspira drain procedure was the patient’s significant other, and not the CG specified in the Plan of Care. On 08/07/25 at 1:00 p.m., the surveyor interviewed the HN (employee F) that visited 06/22/25 for the demonstration of care provided by the patient’s 16-year-old child. The HN stated they watched the child perform the rest of the dressing procedure and that they did not use a sterile dressing kit. Employee F stated sterile dressing kits were not available in the home during this visit and the Nurse Manager was aware. The HN also stated the Nurse Manager said they could substitute a PICC (peripherally inserted central catheter) line dressing kit if the Apsira sterile dressing kits were unavailable, but neither of the kits had been used during the observed procedure.On 08/07/25 at 2:30 p.m., the surveyors interviewed the Palliative Physician who stated they would prefer care of the Aspira drain was scheduled so the 16-year-old child didn’t have to do it.On 08/07/25 at 3:40 p.m., the surveyor interviewed RN Manager B who stated they were unable to get the sterile dressing kits, they were substituting the PICC line dressing kits and using a larger Tegaderm (thin, transparent, and breathable “second skin” for wounds) to cover.The agency failed to ensure the hospice nurses followed the IDG/Care Plan as follows: - ensure the ordered caregiver performed the task - ensure the order included detailed steps and identified specific materials necessary to perform consistent, sterile, dressing changes - identify when the IDG/Care Plan was not followedHome Visit2. Patient #3 was admitted to the hospice on 03/05/25 with a terminal diagnosis of malignant neoplasm (cancer) of lower third of the esophagus.The IDG/Care Plan dated 07/30/25 included orders for enteral tube site care as follows:To be performed twice a week by hospice nurse, cleanse surrounding skin with normal saline, pat dry, apply anti-fungal, apply 4x4 split gauze around tube, secure with tape.On 08/05/25 at 12:00 p.m., the surveyor performed an observational home visit with the hospice nurse. During the visit, the surveyor observed the hospice nurse perform enteral site care. The hospice nurse: - removed the old dressing, which was secured with Tegaderm (transparent adhesive dressing cover) - cleansed the surrounding skin with normal saline - patted the area dry - applied anti-fungal powder - applied 4x4 split gauze around tube - applied a Tegaderm over the split gauze and tube siteOn 08/06/2025 at 12:45 p.m., the surveyor interviewed the hospice nurse that was observed performed the dressing change. They stated they used the Tegaderm to secure the gauze instead of the ordered tape because the patient preferred it and it was more secure.The hospice nurse failed to follow the IDG/Care Plan, or obtain an order and update the plan, to use Tegaderm instead of tape.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the RN Managers who acknowledged the findings and provided no additional information.”

“Based on a review of patient care records, and interviews with agency staff, it was determined for 1 of 18 patients (patient #2), the agency failed to ensure the patient and/or caregivers received education and training on providing care per the IDG Care Plan. Evidence as follows: The Hospice Patient Education policy, dated 04/24/25, included demonstration, re-demonstration, and response to teaching of care and treatment must occur between the clinician and patient/caregiver.The hospice policy titled Interdisciplinary Team Care Planning and Coordination of Care, dated 11/05/24, included the hospice must ensure that each patient and the primary caregiver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care.Home visit1. Patient #2 was admitted to the hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.Aspira drain (a thin, soft tube surgically placed into abdomen to help drain excess fluid) The Interdisciplinary Group (IDG)/Care Plan dated 06/13/25 included:Problem: Drains/Wound Care- Aspira Drain left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by hospice RN (HN) or caregiver [name of patient’s parent identified]. Intervention: Abdominal drain dressing change:- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25, the HN visited the patient to perform an initial assessment and documented: - CG (earlier in vist note identified as significant other [SO]) reports Aspira drain was accessed twice today with 1,000 cc clear yellow fluid drained at 0830, and 700 cc clear yellow fluid drained (no time noted). - CG [SO] describes process of draining Aspira drain, is competent in accessing drain, drain can be accessed by hospice RN or CG in AM and PM, PRN, no more than 1,000 cc taken off at a time.” - CG [SO] and patient declined a full skin assessment at the admission visitAt the end of the visit documentation, the HN documented “next HN visit Saturday, post admission follow-up, comfort pack education, comfort, pain, safety, Aspira drain.”On 06/14/25, the HN visited and documented the visit was to include “comfort pack education”. There was no evidence the HN educated the CG regarding the drain site or dressing care.On 06/17/25, the HN visited the patient and documented teaching was provided regarding the daily frequency of Aspira drain to be accessed and drained. The CG had been accessing and draining 3 times per day as done in the hospital. On 06/22/25, the HN visited to observe demonstration of the caregiver‘s ability to perform drainage and to perform site care of the Aspira abdominal drain. The CG observed was patient’s 16-year-old child who was not identified in the physician’s order as individual to perform.The HN documented the CG had items needed nearby on the overbed table and opened supplies needed. They proceeded to remove the old dressing and then applied sterile gloves and using sterile technique set up the drainage system, cleaned the tubing and accessed it. The fluid was allowed to flow until the bag had 1,000 cc which was then dumped into the toilet and the garbage was disposed of in a garbage bag.There was no evidence the CG completed a demonstration of site care including site cleansing and redressing, hand hygiene prior to and after removal of the soiled dressing prior to donning the sterile gloves, or that the HN provided education regarding same. Pressure ulcerOn 06/20/25, the HN documented: - patient has a superficial wound on the coccyx. Wound care provided - wound cleansed with wound cleanser, patted dry, applied small amount of calmoseptine and covered with foam bordered dressingThe IDG/Care Plan plans dated 07/22/25 and 08/05/25 included: Intervention: Treatment of wound (site #1)Frequency: Selected Visits Wound care to Stage 2 PU on coccyx. Cleanse w/ wound spray, pat dry w/ sterile gauze and cover w/ foam border dressing, change every 3 days or PRN is dislodged or soiled. Completed by (name of significant other) or HN.There was no evidence the caregiver(s) was educated on performing wound care to the patient’s coccyx per the care planOn 07/23/25, the HN documented assessment of the coccyx wound, stage 2 pressure ulcer noted, and wound care provided. On 08/05/25 at 2:00 p.m., the surveyor interviewed the caregiver who stated neither they, nor any caregiver, received training on the procedure to change the coccyx dressing nor did they receive any Calmoseptine.The hospice failed to ensure appropriate caregiver education and training was provided for tasks identified in the Care PlanFailure to provide appropriate education and training to patients and caregivers had the potential for deterioration of the pressure ulcer and this patient developing an infection.”

“Based on clinical record reviews and interviews with the Director of Patient Services and RN Managers, it was determined in 4 out of 18 records (patients #2, 4, 10, and 12), the plan of care failed to address all identified problems and lacked individualization.Evidence as follows: Home visit1. Patient #4 was admitted to the hospice on 06/26/25 with terminal diagnosis of interstitial lung disease and additional diagnoses that included COPD with exacerbation, congestive heart failure, and chronic kidney disease.On 08/05/25, the surveyor conducted a home visit with the Hospice Nurse. During the home visit the patient, caregiver, and nurse discussed the use of “stockings” that patient used on days they don’t elevate their legs. Following the visit, the surveyor interviewed the caregiver about the stockings. The caregiver confirmed these are compression stockings that they apply when bilateral lower extremities are swollen or on days the patient won’t be elevating their lower extremities.The Interdisciplinary Group/Care Plan effective from 07/24-08/06/25 failed to include an order for the compression stockings.On 08/06/25 at 11 a.m., the surveyor interviewed the employee G about the compression stockings, and they reported they were likely ordered by a community provider prior to hospice enrollment, and not ordered by a hospice provider. The nurse also reported that the stockings should have been included in the patient’s plan of care.2. Patient #10 was admitted to the hospice on 04/09/25 with a terminal diagnosis of Alzheimer’s and additional diagnoses that included asthma, chronic kidney disease, and venous insufficiency.On 04/29/25 the Hospice Nurse visited the patient and documented that the staff at the skilled nursing facility where the patient resided was using prophylactic barrier cream to buttock and perineal area and Gold Bond powder to skin creases. The staff was also applying Tubigrips (tubular bandage) to lower extremities for edema management.On 05/13/25 the hospice nurse visited the patient, documented that they assisted the aide in performing peri-care, and barrier creams applied to buttock/perineal area.On 06/18/25 the hospice nurse visited the patient and documented the staff was using: - Dermasavers (fabric tubes to protect skin) on bilateral lower extremities to prevent bruising during transfers and when patient was out of bed - Tubigrips underneath the Dermasavers, Tubigrips were being applied before getting out of bed and removed at night - Calmoseptine ointment to buttocks daily for skin protection - Gold Bond powder to bilateral breasts and groin daily for skin integrity The 07/09/25 and 08/06/25 Interdisciplinary Group Meeting/Care Plans failed to include: - Tubigrips to bilateral lower extremities - Dermasavers over the Tubigrips on the bilateral lower extremities - barrier cream(s) to buttocks and perineal area - Gold Bold powder to skin creases such as breasts and groinOn 08/06/25 at 2:45 p.m., the surveyor interviewed employee B, who reported that treatments such as Tubigrips for edema, barrier creams, and powders should have been included in the plan of care. 3. Patient #12 was admitted to the hospice on 06/27/25 with terminal diagnosis of lung cancer with metastasis (when cancer spreads) to the brain.On 08/05/25, the hospice nurse visited the patient and documented new (2+) pitting edema (swelling) of bilateral feet with the patient reporting this had happened in the past. Patient had their own pair of compression stockings, and the patient reported they could independently apply.The 07/16/25 Interdisciplinary Group Meeting/Care Plan failed to include the compression socks for edema management.On 08/06/25 at 2:45 p.m., the surveyor interviewed employee B, who reported that treatments such as compression stockings should have been included in the plan of care. The hospice’s Interdisciplinary Team Care Planning and Coordination of Care policy dated 11/05/24 included: - B. Plan of Care: All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplary group (IDG) in collaboration with the attending physician, the patient or reporesentative and the primary caregiver in accordance with the patient’s needs if any of them so desire.The hospice must ensure that each patient and the primary caregiver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care.The Hospice’s Patient Education policy dated 04/24/25 included procedural step #2 as follows: - Demonstration, re-demonstration, and response to teaching of care and treatment must occur between the clinician and patient/caregiver. Patient #2 was admitted to the Hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.The initial Interdisciplinary Group Meeting/Care Plan dated 06/13/25 included the patient had an Aspira Drain (a thin tube surgically inserted used to drain excess fluid from the abdomen) and included orders for care by the agency nurse or caregiver as follows:- Aspira Drain – location left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by Hospice RN or caregiver (CG) and listed only the patient’s parent. Change dressing weekly or when accessed for drainage.- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25, during the initial visit employee C determined the drain had been accessed and redressed twice and asked the patient’s significant other (SO) to verbally demonstrate competency for the Aspira procedures. On 06/22/25, employee F visited to observe the caregiver demonstrate draining and redressing the drain site and documented the observation up to the disposal of the fluid drained from the tube but failed to document further steps.The caregiver observed was the patient’s 16 yea-old-child. On 08/07/25 at the surveyor interviewed employee F who stated the did observe the child cleanse the drain site and cover with an ABD pad (thick dressing pad).The surveyor determined no other demonstration attempts had occurred and a complete demonstration of the care (utilizing the ordered sterile dressing kit) had not occurred.The Interdisciplinary Group Meeting/Care Plan failed to include: - orders for accurate family members providing care - an order for the hospice to determine caregiver competency - alternate dressing order if sterile dressing kit unavailable Home visit1. Patient #2 was admitted to the hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.The Interdisciplinary Group (IDG)/Care Plan dated 06/13/25 included the patient had an Aspira Drain (a thin tube surgically inserted used to drain excess fluid from the abdomen) and included orders for care by the agency nurse or caregiver as follows:Problem: Drains/Wound Care- Aspira Drain left upper lateral abdomen. Access in AM and PM PRN (as needed). Parameters, 1,000 cc max drainage per procedure, may be completed by hospice RN (HN) or caregiver [name of patient’s parent identified]. Intervention: Abdominal drain dressing change:- Change dressing weekly, use sterile dressing change kit weekly or when accessed for drainage.On 06/13/25, during the initial visit the hospice nurse (HN) determined the drain had been accessed and redressed twice and asked the patient’s significant other (SO) to verbally demonstrate competency for the Aspira procedures. On 06/22/25, the HN visited to observe a different caregiver(the patient’s 16-year-old-child) perform/demonstrate the care. The procedure demonstrated was not in accordance with the IDG Care Plan (see also L 543). The IDG Care Plan failed to include all family members that would be providing care to the patient’s Aspira drain including, accessing the drain, dressing change orders to the drain site, and caregiver competency to provide care to the Aspira drain in the absence of the hospice RN.Home visit2. Patient #4 was admitted to the hospice on 06/26/25 with terminal diagnosis of interstitial lung disease (lung disorder where the tissue surrounding the air sacs becomes inflamed, stiff, or scarred) and additional diagnoses that included chronic obstructive pulmonary disease (COPD) with exacerbation, congestive heart failure, and chronic kidney disease.On 08/05/25 at 10:00 a.m., the surveyor conducted a home visit with the Hospice Nurse (HN). During the home visit the patient, caregiver, and HN discussed the use of “stockings” that patient used on days they don’t elevate their legs. Following the visit, the surveyor interviewed the caregiver about the stockings. The caregiver stated they wear the compression stockings when bilateral lower extremities are swollen or on days when they will not be elevating their lower extremities.The IDG/Care Plan effective from 07/24-08/06/25 failed to include an order for the compression stockings.On 08/06/25 at 11:00 a.m., the surveyor interviewed the HN (employee G) about the compression stockings, and they reported they were likely ordered by a community provider prior to hospice enrollment, and not ordered by a hospice provider. The nurse also reported that the stockings should have been included in the patient’s plan of care.3. Patient #10 was admitted to the hospice on 04/09/25 with a terminal diagnosis of Alzheimer’s disease and additional diagnoses that included asthma, chronic kidney disease, and venous insufficiency (condition where the veins in the legs have difficulty sending blood back to the heart).On 04/29/25 the HN visited the patient and documented that the staff at the skilled nursing facility where the patient resided were using prophylactic barrier cream to buttock and perineal area and Gold Bond powder to skin creases. The staff were also applying Tubigrips (tubular bandage) to lower extremities for edema management.On 05/13/25 the HN visited the patient, documented that they assisted the aide in performing peri-care, and barrier creams applied to buttock/perineal area.On 06/18/25 the HN visited the patient and documented the staff was using: - Dermasavers (fabric tubes to protect skin) on bilateral lower extremities to prevent bruising during transfers and when patient was out of bed - Tubigrips underneath the Dermasavers, Tubigrips were being applied before getting out of bed and removed at night - Calmoseptine ointment to buttocks daily for skin protection - Gold Bond powder to bilateral breasts and groin daily for skin integrity The 07/09/25 and 08/06/25 IDG/Care Plans failed to include: - Tubigrips to bilateral lower extremities - Dermasavers over the Tubigrips on the bilateral lower extremities - barrier cream(s) to buttocks and perineal area - Gold Bold powder to skin creases such as breasts and groinOn 08/06/25 at 2:45 p.m., the surveyor interviewed the Nurse Manager (employee B), who reported that treatments such as Tubigrips for edema, barrier creams, and powders should have been included in the plan of care. 4. Patient #12 was admitted to the hospice on 06/27/25 with terminal diagnosis of lung cancer with metastasis (when cancer spreads) to the brain.On 08/05/25, the hospice nurse visited the patient and documented new (2+) pitting edema (swelling) of bilateral feet with the patient reporting this had happened in the past. Patient had their own pair of compression stockings, and the patient reported they could independently apply.The 07/16/25 IDG/Care Plan failed to include the compression stockings for edema management.On 08/06/25 at 2:45 p.m., the surveyor interviewed the RN Manager (employee B), who reported that treatments such as compression stockings should have been included in the plan of care. On 08/11/25 at 11:45 a.m., the record was reviewed with the Director or Patient Services and RN Managers. They acknowledged the findings and provided no additional information. Failure of the hospice to develop a complete and individualized plan of care that defines roles and addresses all patient needs has the potential for unmet needs and possible negative outcomes for all hospice patients.”

“Based on clinical record review and staff interviews, the hospice failed to ensure the Interdisciplinary Group Meeting/Care Plan included the necessary treatments to assist in the management of the terminal illness for 2 of 18 patients (patients #4 and 13). Evidence as follows: Patient #13 was admitted to the hospice on 4/29/25 with a terminal diagnosis of prostate cancer and additional diagnoses of pulmonary embolism and chronic obstructive pulmonary disease.In the hospice admission assessment on 4/29/25, the hospice nurse documented under the “Respiratory” section, the patient uses 2 liters of supplemental oxygen.On 5/13/25, the hospice nurse documented the patient was wears 2 liters of supplemental oxygen overnight and as needed during the day. On 7/8/25, the hospice nurse documented the family is no longer making the patient wear his oxygen at nighttime and that he has not worn it in approximately 1 week.On 7/15/25, the hospice nurse documented the patient was using oxygen a night often.On7/22/25, the hospice nurse documented the patient was not wearing oxygen upon arrival but was applied during the visit. The hospice nurse also documented they discussed the use of oxygen in hospice care to promote comfort and the patient’s significant other made the decision to apply the oxygen.On 7/29/25, the hospice nurse documented the patient was wearing oxygen almost continuously for a week.On 8/1/25, the hospice nurse documented the patient was using 2 liters of oxygen via nasal cannula “most of the time”.On 8/8/25, the hospice nurse documented the family reported the patient was wearing 2 liters of oxygen via nasal cannula “more often than not” for comfort.The following Interdisciplinary Group Meeting/Care Plans do not contain orders for oxygen administration: - 4/28/25 - 5/1/25 - 5/14/25 - 5/28/25 - 6/11/25 - 6/25/25 - 7/9/15On 8/6/25 at 11:10 a.m., the surveyor conducted a phone interview with the patient’s hospice nurse. They confirmed that upon medication review, it was recognized that oxygen was not on the patient’s Interdisciplinary Group Meeting/Care Plan or medication list. They confirmed that oxygen should have been listed on the patient’s medication list as part of the Interdisciplinary Group Meeting/Care Plan.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the registered nurse managers who acknowledged the findings and provided no additional information. Home VisitPatient #4 was admitted to the hospice on 06/26/25 with terminal diagnosis of interstitial lung disease and additional diagnoses that included COPD with exacerbation, congestive heart failure, and chronic kidney disease.The Interdisciplinary Group Meeting/Care Plan effective from 07/24-08/06/25 included an order for acetaminophen (Tylenol) 500 mg, take 1 tablet twice daily orally.On 08/05/25, the surveyor conducted a home visit with the hospice nurse. During the visit, the nurse reviewed the medications in the home with the caregiver. Following the visit, the surveyor interviewed the caregiver about the medications. The caregiver reported that the patient used to take Tylenol twice a day, but this was months ago and predated the hospice admission. The caregiver reported the patient rarely used Tylenol for the past few months but occasionally takes it as needed for pain.Next to the patient’s medications was a bottle of MiraLAX. The caregiver reported that they were administering this if the patient had not had a bowel movement in a couple of days.The care plan failed to include MiraLAX or the accurate frequency of Tylenol.On 08/06/25 at 11 a.m., the surveyor interviewed employee G about the MiraLAX and the Tylenol. The nurse reported that they were able to review the Tylenol order, identified it had a start date of 06/27/25, and the order originated from the community provider. They were unaware the patient was not using the Tylenol twice a day and had been using it as needed only. They also reported they were unaware the patient had been using MiraLAX and because no one had reported constipation, the patient had not been escalated to a bowel regimen.”

“Based on clinical record review, and staff interviews, for 1 of 18 patients (patient #2) the hospice failed to ensure the Interdisciplinary Group Meeting/Care Plan included all necessary medical supplies and appliances for the management of the patient’s terminal illness . Evidence as follows: The hospice’s Safe Effective Use of Equipment and Supplies policy, dated 06/23/25, included: - Patients will receive information regarding the safe and effective use of durable medical equipment (DME) and medical supplies. Hospice staff support patient teaching when another organization supplies equipment. - The clinician will, through interview and observation, determine the patient, family, or caregiver’s levels of understanding in the use of the DME. - Equipment includes but is not limited to mechanical liftsHome visit1. Patient #2 was admitted to the hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.Durable Medical EquipmentOn 06/13/25, during the initial visit, the HN documented: - patient was weak, however, was capable of partial weight bearing and was able to transfer out of bed to commode with 1 assistant - family was able to assist the patient to transfer onto electric scooterOn 06/14/25 , the HN documented, “patient was tearful because only his adult son can get him up to the restroom” and was asking about alternatives to assist with moving. The HN documented, “writer explained that we don’t utilize lifts or have any type of machines to help lift like the patient was requesting.” On 06/17/25, the HN documented: - “[significant other] obtained a Hoyer lift (a mechanical device designed to safely lift and transfer individuals who have limited mobility) paying out of pocket.” - [significant other] was upset throughout the visit as they were under the impression hospice supplied the Hoyer lift. They reported being told that while patient was in the hospital and that it was the only way they could get them out of bed to the commode or onto the scooter.On 06/24/25, the hospice licensed practical nurse documented the patient was up utilizing electric scooter.The same day the medical social worker (MSW) visited and documented the patient was up on the scooter cooking lunch for their child. The patient’s parent reported they had done similar tasks over the weekend and the patient expressed happiness to be able to do this task.On 06/26/25, the MSW reported the patient was up on the scooter planning to make burritos for the family.On 07/01/25, the MSW documented the family transferred the patient to bed during the visit using the Hoyer lift.On 07/03/25, the HN documented the patient had just returned from the interventional radiology procedure and [significant other] utilized the Hoyer to transfer patient to the bed.On 07/18/25, the HN documented, received patient in bed but is Hoyer lifted out of bed daily to scooter.On 07/25/25, the HN documented, “patient purchased a Hoyer lift from [online used items market] due to it being much cheaper than to rent the current one.”On 08/05/25 at 10:45 a.m., the surveyor attended the Interdisciplinary Group (IDG) meeting where the HN discussed the family purchasing a Hoyer lift online which was less expensive than rental from a local medical supply company. No further discussion regarding the cost of the Hoyer or coverage of the equipment occurred.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director or Patient Services and RN Managers. They acknowledged the findings and provided no additional information. The Care Plan lacked documented evidence of the assessment, use or educational needs related to the Hoyer lift.Failure to ensure all necessary medical supplies and appliances are incorporated into the care plan has the potential to result in the provision of incorrect and/or inaccurate care, unmet patient needs and negative patient outcomes.”

“Based on clinical record review, and staff interviews, for 1 of 18 patients (patient #2) the hospice failed to ensure the care and services provided were based on all assessments of the patient and family needs. Home visit1. Patient #2 was admitted to the Hospice on 06/13/25 with a terminal diagnosis of pancreatic cancer.On 08/05/25 at 10:45 a.m., the surveyor attended the Interdisciplinary Group (IDG) meeting where the HN discussed the family purchasing a Hoyer lift online which was less expensive than rental from a local medical supply company. No further discussion regarding the cost of the Hoyer or coverage of the equipment occurred.On 08/05/25 at 2:00 p.m., the surveyor conducted an observational home visit. Afterward, the surveyor interviewed the patient and family who stated:-They were upset they had to pay for the Hoyer themselves. It had been explained in the hospital the hospice program paid for them.-They had all gone to the medical supply store to pick up the Hoyer where they were trained in its use; “they even put my son it and had us learn how to use it.”On 08/06/25 at 2:15 p.m., the surveyor interviewed the HN (employee H) that visited 07/03/25 who stated, “on the way out of the home I did see the family use the Hoyer but did not observe them use it. They (Hoyer lifts) are not covered as they are not part of the hospice philosophy.”On 08/06/25 at 2:50 p.m., the surveyor interviewed the RN Manager (employee B) who stated they don’t cover Hoyer lifts as they are not considered safe as patients decline and that there was no funding for the use of the Hoyer.On 08/07/25 at 12:14 p.m., the surveyor interviewed the HN (employee D) who visited 06/14/25, they stated there are safety concerns with Hoyer use, they do nottypically encourage them due to the training required. They do not have the staff or time to train for Hoyer use.On 08/07/25 at 3:40 p.m., the surveyor interviewed the RN Manager (employee A) who stated, they generally discourage Hoyer lifts for safety reasons, however they doreview on a case-by-case basis.The was no evidence the hospice IDG discussed:- whether the family was using the Hoyer safely and appropriately- whether the patient was benefitting from the Hoyer- whether the Hoyer should be covered to meet this patient’s specific needs under the hospice benefitOn 08/11/25 at 11:45 a.m., the record was reviewed with the Director or Patient Services and RN Managers. They acknowledged the findings and provided no additional information. The hospice failed to assess whether Hoyer lift was being used safely in the home and consider on a case by case basis whether the it benefitted the patient’s end of life quality.”

“Based on a review of Quality Assurance Performance Improvement (QAPI) committee meeting minutes and interviews with the Director of Patient Services and RN Manager 1, there was no evidence that the hospice used the data collected by the agency to monitor the effectiveness and safety of services, the quality of care provided, or to identify opportunities and priorities for improvement. The 07/21/25 Hospice Quality Assurance/Performance Improvement Committee meeting minutes reflected the agency conducted several focused audits including home health aide care plans, bereavement, end of live visits, and Interdisciplinary Group Care Plans.The focused audits failed to recognize issues identified during the survey, including:- comprehensive assessments (L523 and L533)- care planning (L543, L544, L545, L549, L550)- supervision of hospice aides (L629)On 08/11/25 at 2:30 p.m., the surveyor interviewed the Director of Patient Services, RN Manager 1, Regulatory Director, and Director of Regional Compliance regarding the agency’s audit process. RN Manager 1 reported that the agency does not perform ongoing comprehensive audits following the start of care, and therefore, no mechanism to identify complaints that were not captured (see tag M0013), care plans that were not updated as needed (see L543, L544, L545, L549, L550). The Director of Patient Services and RN Manager 1 reported that the transition to a new electronic medical record earlier this year had been a barrier, however, there was no evidence comprehensive audits were completed prior to the change in electronic medical record.The agency also had no mechanism to monitor the effectiveness of the symptom management (such as pain relief, dyspnea, secretions, anxiety/agitation) that is inherent to hospice services.The agency also failed to analyze the data collected and develop an action plan. During the interview, RN Manager 1 discussed “CTIs” (Care Transformation Initiatives), however, they did not discuss the action plans derived from them.Failure of the hospice to analyze the data collected to monitor their services and identify opportunities and priorities for improvement has the potential for the agency to be unable to self-identify problems that exist within the hospice. This can result in unmet patient needs, and possible negative patient outcomes.”

“Based on observational home visits, review of the hospice’s policy and procedure for infection control standards and practices, it was determined during 1 of 4 observational home visits (patient #3), the hospice nurse failed to adhere to accepted standards and practices to prevent transmission of infection.Evidence as follows: Home VisitPatient #3 was admitted to the hospice on 03/05/25 with a terminal diagnosis of malignant neoplasm of lower third of the esophagus (cancer).On 08/05/25 at 12:00 p.m., the surveyor performed an observational home visit with the hospice nurse.The Interdisciplinary Group Meeting/Care Plan dated 07/30/25 included orders for enteral tube site care as follows:To be performed twice a week by hospice nurse, cleanse surrounding skin with normal saline, pat dry, apply anti-fungal, apply 4x4 split gauze around tube, secure with tape.During the visit, the surveyor observed the hospice nurse perform enteral tube site care.The nurse laid out all the supplies and without performing hand hygiene, applied gloves. They then removed the old dressing and discarded it along with their gloves and applied new gloves. The nurse did not perform hand hygiene in-between glove changes. The nurse then cleansed, dried, and re-dressed the wound. The nurse then discarded their gloves and did not perform hand hygiene.On 08/06/2025 at 12:45 p.m., the surveyor interviewed via phone the hospice nurse that was observed performing the dressing change. They stated that while doing the dressing change, hand hygiene should be performed between glove changes.Per the agency’s “Hand Hygiene” policy, dated 01/04/24, hand hygiene with alcohol-based hand gel must be performed immediately after glove use.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the registered nurse managers who acknowledged the findings and provided no additional information.”

“Based on clinical record review of 5 patients receiving paraprofessional aide services (patients #5, 6, 11, 12 and 13), and staff interviews, it was determined in 2 out of 5 records (patient #5 and 6), the hospice failed to ensure professional staff made an onsite visit to the patient’s home at least every fourteen days to supervise the hospice aide.Evidence as follows: Patient #6 was admitted to the agency on 03/26/25 with terminal diagnoses of chronic obstructive pulmonary disease (COPD). The 03/26/25 Hospice Plan of Care included hospice aide services twice weekly. The aides provided services to the patient on 04/2, 04/9, 04/11, 04/14, 04/18, and 04/21/21. The first documented aide supervision was on 04/23/25, 3 weeks after the patient began receiving aide services.Aide supervision occurred at least every two weeks as required from 04/23-06/18/25. Aides provided services to the patient on 06/23, 06/30, and 07/07/25. There was no documented aide supervision during the three-week period between 06/18 and 07/09/25. On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and Registered Nurse Managers.On 08/12/25 at 11:17 a.m. the surveyor interviewed the RN Manager (employee A) and asked whether there was any explanation for the missed aide supervision visits. The RN manager confirmed the findings that documented aide supervision was missing and stated it was the same nurse involved in both supervision time gaps.No additional information was provided. Patient #5 was admitted to the agency on 1/30/25 with a terminal diagnosis of heart failure.The Interdisciplinary Group Meeting/Care Plan dated 6/24/25 documented the patient was receiving home health aide visits twice weekly.On 7/1/25, the hospice nurse documented an aide supervision note.The patient received aide services on 7/3/25 and 7/8/25.The hospice nurse visited the patient on 7/9/25 and failed to document any aide supervision. The next documented aide supervision was 7/17/25; 16 days after the 7/1/25 aide supervision was documented.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the registered nurse managers.On 8/12/25 at 11:17 a.m., the surveyor interviewed the registered nurse manager who acknowledged that the nurse did not document an aide supervision during the 7/9/25 visit.The hospice nurse failed to ensure that the aides were receiving supervision every 14 days. 1. Patient #5 was admitted to the agency on 1/30/25 with a terminal diagnosis of heart failure.The Interdisciplinary Group Meeting/Care Plan dated 6/24/25 documented the patient was receiving home health aide visits twice weekly.On 7/1/25, the hospice nurse documented an aide supervision note.The patient received aide services on 7/3/25 and 7/8/25.The hospice nurse visited the patient on 7/9/25 and failed to document any aide supervision. The next documented aide supervision was 7/17/25; 16 days after the 7/1/25 aide supervision was documented.On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and the registered nurse managers.On 8/12/25 at 11:17 a.m., the surveyor interviewed the registered nurse manager who acknowledged that the nurse did not document an aide supervision during the 7/9/25 visit.The hospice nurse failed to ensure that the aides were receiving supervision every 14 days.2. Patient #6 was admitted to the agency on 03/26/25 with terminal diagnoses of chronic obstructive pulmonary disease (COPD). The 03/26/25 Hospice Plan of Care included hospice aide services twice weekly. The aides provided services to the patient on 04/2, 04/9, 04/11, 04/14, 04/18, and 04/21/21. The first documented aide supervision was on 04/23/25, 3 weeks after the patient began receiving aide services.Aide supervision occurred at least every two weeks as required from 04/23-06/18/25. Aides provided services to the patient on 06/23, 06/30, and 07/07/25. There was no documented aide supervision during the three-week period between 06/18 and 07/09/25. On 08/11/25 at 11:45 a.m., the record was reviewed with the Director of Patient Services and Registered Nurse Managers.On 08/12/25 at 11:17 a.m. the surveyor interviewed the RN Manager (employee A) and asked whether there was any explanation for the missed aide supervision visits. The RN manager confirmed the findings that documented aide supervision was missing and stated it was the same nurse involved in both supervision time gaps.No additional information was provided.”