Bayada Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 ( 33%) home visits observed and clinical records reviewed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient’s current medications to identify any actual or potential drug interactions. HOME VISIT 2/CLINICAL RECORD 2: This patient elected the hospice benefit on 04/08/2026 with a terminal diagnosis of unspecified symptoms and signs with cognitive function and awareness/dementia. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 06/09/2026, the hospice medication profile and the ALF medication administration record (MAR), both dated 06/09/2026, were compared. The ALF MAR documented Nystatin 100,000 units applied under both breasts twice a day. Nystatin was not documented on the hospice medication profile. During a joint clinical review and interview on 06/09/2026, the Administrator, who attended the home visit and reviewed the facility MAR, stated that the hospice medication profile was inaccurate and that the patient’s Registered Nurse Case Manager (RNCM) had stated they had forgotten to review the facility treatment record. The Administrator stated that the RNCMs would be re-educated to always review treatment records in facilities.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the Interdisciplinary group (IDG) provided coordination of care and the continuous assessment of the patient’s and family’s needs. CLINICAL RECORD 14: This patient elected the hospice benefit on 02/20/2026 with a terminal diagnosis of hypertensive heart disease, chronic kidney disease, and heart failure. A review of the clinical record revealed a significant change in the patient’s condition prior to death. A Nurse Practitioner (NP) face-to-face encounter dated 04/09/2026 documented that the patient had experienced a choking episode resulting in loss of consciousness and increased fatigue. The cardiologist reported that the automatic implantable cardioverter defibrillator (AICD) had discharged in response to a fatal arrhythmia. A PRN (as needed) Registered Nurse (RN) visit conducted on Saturday, 04/11/2026, documented that the “patient was unresponsive, experiencing 15-second periods of apnea, had an oxygen saturation of 79% on room air, audible upper airway secretions, and required placement of a magnet over the AICD.” The family was “instructed on end-of-life symptoms and to call hospice if the patient should pass.” The next Skilled Nurse (SN) visit was on Monday, 04/13/2026 at 11:31 AM, during which it was documented that the patient was obtunded, with 15 seconds of apnea and gurgling during respirations, and that the SN was unable to obtain SpO2 (peripheral oxygen saturation) and blood pressure (B/P). The patient was pronounced deceased at 3:43 PM on 04/13/2026. A clinical record review revealed no evidence that the SN communicated the patient’s decline to the Interdisciplinary group (IDG) on 04/11/2026. The hospice plan of care for 04/11/2026 through 04/13/2026 was not updated to reflect the patient’s changing needs. There was no documentation of a follow-up SN visit or phone call to assess the patient’s status, symptom management needs, or family needs following the documented decline on 04/11/2026. During a joint clinical review and interview on 06/08/2026, the Administrator stated that the SN should have notified the IDG regarding the patient’s significant decline and should have made a follow-up visit on 04/12/2026.”

“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 and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #0-1169 “Hand Hygiene” stated in part, “Indications for hand decontamination.... a. Before and after having any direct contact with intact skin. b. Before and after removing gloves. c. Between contact with the environment/inanimate objects and the client. e. Before moving from a contaminated body site to a clean-body site during client care.” In 1 of 3 (33%) home visits observed, the agency did not ensure hand hygiene was performed when indicated per the agency’s policy. HOME VISIT 2/CLINICAL RECORD 2: This patient elected the hospice benefit on 04/01/2026 with a terminal diagnosis of cirrhosis of the liver. During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 06/09/2026, the HA washed their hands and donned gloves. During the patient’s bed bath, the lotion fell to the floor and the HA picked up the lotion bottle from the floor and placed it back on the patient’s over-the-bed table without cleaning the lotion bottle or sanitizing their hands. During an interview on 06/09/2026, the Administrator, who was present for the home visit, stated that the HA was not following the agency policy for infection control and the HA would be re-educated.”

“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 9 (11%) clinical records reviewed in which Hospice Aide services were provided, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 4: This patient elected the hospice benefit on 03/15/2026 with a terminal diagnosis of breast cancer. The hospice plan of care dated 03/15/2026 ordered HA services 5 times per week, skilled nurse (SN) or a caregiver to drain the patient’s Aspira drain for comfort, and dressing changes every 7 days by the SN. The HA care plan for the period 03/15/2026 through 06/08/2026 did not include instructions for the HA related to the care or monitoring of the Aspira drain dressing, should it become wet, soiled, or dislodged during personal care. During a joint clinical review and interview on 06/08/2026, the Administrator stated that the HA care plan did not include instructions for the Aspira drain and it would be updated to ensure to provide the HA with instructions that were clear and understandable.”