Complete Hospice Care

“Based on administrative record review and interview, the agency failed to review and update a facility-based and community-based Hazards Risk Assessment at least every 2 years for each service location. Review of the agency’s Emergency Preparedness Plan for the main provider location and 2 branch locations, failed to provide current and complete Hazard Risks Assessments for each service location. During an interview on 05/14/26 at 08:30AM, Staff C provided evidence the Hazard Risks Assessments were updated during the survey and stated the Hazard Risks Assessments were not completed and updated at least every 2 years as required for each location.”

“Based on record review and interview, the agency failed to timely report suspected patient mistreatment, neglect or abuse to authorities as required for one (#19) of (#1 - #23) records reviewed. This failure to report suspected mistreatment, neglect or abuse timely to the appropriate authorities, had the potential to prevent the agency from ensuring a safe care environment and from meeting the patient’s specific care needs and progressing towards outcomes or goals identified in the patient specific POC. Patient #19Review of the SOC for Patient #19 initial certification period 04/08/25 - 07/06/25 showed a primary diagnosis of unspecified severe protein calorie malnutrition with a stage 3 pressure ulcer to the left heel and complete bedrest with contractures of upper and lower extremities. Additional documentation showed the patient resided at home with daughter and son as primary caregivers. The POC contained orders for SN visits 3 times a week for 13 weeks and 6 PRN visits, HHA visits 6 visits a week for 13 weeks and MSW visits 1 time for 1 month, 2 times for 2 months and 3 PRN visits. Wound care orders for the left heel wound were 3 times a week and PRN with and additional order that stated,” SN to teach patient/caregiver/facility nurse to perform”. Further review of SN documentation showed additional wounds were identified to the sacrum and right buttock on 06/06/25 and additional deterioration with new wounds to the right hip, left hip and right foot 5th metatarsal on 06/27/25. Physician orders included SN visits to increase to 6 times per week and for SN to perform wound care daily and PRN to the sacral wound. The addition of an antibiotic to be applied directly to the sacral wound bed to control wound odor was ordered to start 07/05/25. No documentation in the record provided evidence the IDT members notified APS of suspected mistreatment, neglect or abuse as required. Review of the initial SW assessment conducted on 04/10/25 identified an intervention to assess/instruct on Long-Term Planning/ Decision with the family. Phone calls from the SW were placed to the daughter on 05/21/25 and 05/58/26 regarding the need for Long-Term care placement or 24 hour care as the patient can not be left alone for any length of time. Further review of SW visit documentation on 06/10/25 and 06/12/25 showed communication with the daughter regarding the patient being left alone without a caregiver. The daughter was informed that APS would be contacted if the family could not ensure the patient would not be left alone. The daughter informed the SW a private care aide was available, but the SW documented the patient still had times without a caregiver present. No documentation in the record provided evidence the SW notified APS of suspected mistreatment, neglect or abuse as required. A referral dated 07/02/25 was sent by the hospice agency to a Long-Term Care facility as the patient required a higher level of care the family could not provide. The patient was transferred to another hospice agency on 07/10/25 with care to be coordinated with the facility staff and new hospice agency. On 05/14/26 at 11:30 AM, the Branch Manager was interviewed regarding the agency’s wound care policy and procedures and documentation for 3 wound care records which included Pt #19. The Branch Manager stated an internal investigation had been conducted regarding Pt #19’s care and services. No documentation in the record provided evidence the agency notified authorities timely of suspected mistreatment, neglect or abuse of Pt #19 as required.”

“Based on record reviews during facility patient visits and interview, the IDT failed to ensure an updated patient specific POC was provided timely to each facility where two (#1 and #2) of four (#1 - #4) facility patients visits and records were reviewed. This failed practice had the potential to prevent all 34 facility patients currently on census from receiving care and services to meet their specific needs. Patient #1Review of the POC for Patient #1 showed a re-certification period of 03/15/26 - 05/13/26 and a primary diagnosis of Chronic Obstructive Pulmonary Disease with orders for SN visits 2 times a week for 8 weeks and 1 time a week for 1 week HA visits 2 times a week for eight weeks and 1 time a week for 1 week.Staff A stated Patient #1 resides at a local facility and a visit was conduct at the facility on 05/13/26 at 8:50AM. Review of the agency records maintained at the facility for Patient #1 failed to provide evidence of a current POC. The last POC titled “Interdisciplinary Team Review” identified in the records was dated for recertification period 07/18/25 - 09/15/25. Patient #2Review of the POC for Patient #2 showed a re-certification period of 04/05/26 - 06/03/26 and a primary diagnosis of Atherosclerotic Heart Disease with orders for SN visits 2 times a week for 8 weeks and 1 time a week for 1 week HA visits 3 times a week for eight weeks and 2 time a week for 1 week.Staff A stated Patient #2 resides at a local facility and a visit was conduct at the facility on 05/13/26 at 9:30AM. Review of the agency records maintained at the facility for Patient #2 failed to provide evidence of a current POC. The last “Interdisciplinary Team Review” identified in the records was dated for recertification period 08/08/25 - 10/06/25. During an interview on 05/13/26 at 10:10AM, Staff A stated the POC titled “Interdisciplinary Team Review” is to be printed after each meeting and are to be delivered to the facility by staff members. Staff A stated the POCs reviewed in the facilities were not current and the agency failed to maintain a current POC in the facilities as required.”