Hospice and Community Care

“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; 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 and interview. In 1 of 22 (5%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 3: The patient elected the hospice benefit on 03/03/2026 for a diagnosis of Volvulus. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the registered nurse (RN) (Personnel Record 4) on 05/12/2026, the hospice medication profile (printed on 05/11/2026) was compared to the SNF medication profile (printed on 05/12/2026). The hospice medication profile contained the following medications not listed on the SNF list: “Robitussin DM 10 ml every 4 hours as needed. (Ordered 04/28/2026)” The last comprehensive nursing visit was 05/07/2026. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/12/2026 during which time it was confirmed that medications should be reconciled with every nursing visit.”

“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 use of gloves. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visits observed, the agency did not ensure clinical staff followed hand hygiene procedures as required by policy. Agency policy titled “Hand Hygiene Policy 5.7.1 dated 2009, revised Feb 2025” stated in relevant parts: “Procedure 1. Indications for hand hygiene are: Before and after direct patient care. After blowing or wiping the nose. Moving from contaminated patient body site to clean body site during patient care. Handwashing recommended. Before handling medication or food. Non-anti-microbial or antimicrobial soap and water.” HOME VISIT 2: During the home visit with the hospice aide (Personnel Record 7) on 05/12/2026, the hospice aide began the visit by washing hands and donned (applied) gloves. The aide then proceeded to give the patient a bed bath and started by washing the patient’s upper body. The aide used a large towel, dipped it in the wash basin to apply soap to the patient, used another large towel, dipped it in the wash basin to rinse the patient and then use a third large towel to dry the patient. The aide then applied lotion to the patient. The aide repeated this process for the perineal area and then washed the patient’s legs and feet, repeating the same process. The aide rolled the patient over and repeated the process on the patient’s back, working from top to bottom. At the end of the bath, after replacing the patient’s top, the aide removed a brush from the patient’s dresser drawer and brushed the patient’s hair. During the entire process, the aide did not change gloves nor wash hands. An interview was conducted with the Administrator, Chief Clinical Officer, and Quality Nurse on 05/12/2026 during which time the home visit was reviewed, and the discussion was surrounding the aide. The leadership team stated the aide “would be retrained immediately on the proper hand hygiene per policy.””

“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 (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 2: The hospice aide care plan updated 05/05/2026 included the following relevant tasks: “Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care” All tasks were to be completed every visit with an aide frequency of twice weekly. A physician’s order dated 02/16/2026 and the medication list noted patient is on “oxygen 2-5 liters continuously for shortness of breath.” The hospice aide care plan did not notify the aide of the oxygen nor provide specific instructions for the aide during tasks. CLINICAL RECORD 4: The hospice aide care plan updated 05/12/2026 included the following relevant tasks: “Check pressure areas with each visit; complete bed bath two times a week; peri care two times a week; document BM (bowel movement) with each visit; document output with each visit; incontinence care with each visit; dress patient after bathing two times per week; hair/scalp care two times per week; change linen weekly and as needed; offer easy to grab foods with each visit; denture/mouth care with each visit; skin care two times per week with each visit.” The hospice aide visit frequency was twice weekly. A physician’s order dated 04/09/2026 noted a “Dressing to great right toe and leave shoe off.” The aide care plan did not notify the aide of the wound nor to notify the nurse if the dressing became soiled, dislodged or wet. CLINICAL RECORD 6: The hospice aide care plan dated 12/19/2025 included the following relevant tasks: “Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care.” All tasks were to be completed every visit with an aide frequency of twice weekly. A physician’s order dated 04/23/2026 noted a “right ankle brace.” The hospice aide care plan did not notify the aide of the brace nor provide the aide with specific instructions for the brace during tasks. CLINICAL RECORD 11: The hospice aide care plan dated 03/25/2026 included the following relevant tasks: “Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care.” All tasks were to be completed every visit with an aide frequency of twice weekly. A nursing visit dated 03/25/2026 noted patient had “boot on foot due to surgery.” The hospice aide care plan did not notify the aide of the boot nor provide the aide with specific instructions for the boot during tasks. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/14/2026 during which time it was agreed the aide care plans “should be modified to be clearer.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits of patients who received hospice aide services, the agency did not ensure that the hospice aide provided services included in the plan of care. HOME VISIT 2: The hospice aide care plan dated 05/05/2026 included the following relevant tasks: “Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; hair care; change linen; denture/mouth care; skin care” All tasks were to be completed every visit with an aide frequency of twice weekly. During home visit with the hospice aide (Personnel Record 7) on 05/12/2026, the aide was observed to remove the oxygen from the patient and place it on the bed beside the patient during the visit. There were not instructions for the aide in the plan of care for this task. The aide was not observed to complete the task of denture/mouth care during the visit. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/12/2026 at which time they agreed that the “aide should complete tasks as ordered per the plan of care.””

“It is required that Hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met as evidenced by document review, interview, and observation. An inspection of the kitchen during life safety code tour revealed the agency did not ensure the hospice followed the accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hygiene and use of gloves. Agency policy titled “Hand Hygiene Policy 5.7.1 dated 2009, revised Feb 2025” stated in relevant parts: “Procedure 1. Indications for hand hygiene are: Before and after direct patient care. After blowing or wiping the nose. Handwashing recommended. Before handling medication or food. Non-antimicrobial or antimicrobial soap and water.” A tour of the hospice owned inpatient unit was conducted on 05/13/2026 with the Administrator (Personnel Record 2), Director of Nursing (Personnel Record 12) and the facilities supervisor. Upon touring the kitchen, Personnel Record 13 (Hospice Aide) was asked to demonstrate how to check the temperature of the food before being served to a patient as this was part of her normal duties. She came over to the counter, showed the thermometer she used, then said “Sorry, my nose is running and I need to blow it.” She went to get a paper towel and blew her nose. After throwing away the paper towel, she returned and picked up the thermometer. She did not wash or sanitize her hands or don (apply) gloves. She then opened the food warmer, removed a carton of food, inserted the thermometer, and showed the temperature reading. She replaced the lid on the food and put it back in the warmer, cleaned the thermometer, and described the process for recording the temperature. The food was immediately removed and destroyed by leadership, and it was advised that the aide would receive immediate training.”

“Upon patient record review, 1 of 5 (Patient #2) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 2: The medical record indicated that the patient was receiving wound care to the blisters on the foot and lower leg. No evidence that education and training with the current wound care orders was given to the primary caregiver. RN documentation indicated that the caregiver is a nurse and is aware of how to change bandages. The primary daughter who lives in town and is available during the week is not a nurse.”