Interim Health Care of the Triad, Inc.

“Based on observation, interview, record review and review of facility policy entitled “;Drugs and Biologicals-Administration, Use and Disposal”, the hospice Registered Nurse (RN) failed to provide and update a current medication list for 3 of 3 patients (Patient #1, #2 and # 3). Record Review of the facilitys policy entitled “;Drugs and Biologicals-Administration, Use and Disposal” dated 2019 showed that the designated RN is to maintain a current medication profile for hospice patients and to verify medication changes with the hospice Medical Director or the patients attending physician. Findings included Observation on 01/14/25 at 9:15 AM showed Patient #1s medication list for the hospice listed Augmentin 875 mg 1 tablet by mouth twice a day for 7 days. Patient #1 caregiver reports patient has not been taking this medication “;for months”. During an interview on 01/16/25, Branch Manager stated that the medication should have been removed from the list. Observation on 01/14/25 at 10:45 AM showed Patient #2s medication listed Tylenol 325 mg 1 tablet by mouth daily. Prescription bottle and caregiver report Tylenol 500 mg 1 tablet by mouth daily and as needed for pain. RN #2 verified the finding at the observation visit on 01/14/25. Observation on 01/14/25 at 12:30 PM showed Patient #3s hospice medication list reports Metoprolol tartrate 25 mg 1 table by mouth daily; caregiver reports patient taking Metoprolol tartrate 25 mg 1 tablet by mouth twice a day. Hospice medication list reports patient taking trazadone 50 mg tablet taking 1.5 tablet by mouth at bedtime; caregiver reports patient taking trazadone 50 mg tablet taking 2 tablets by mouth at bedtime. Caregiver reports patient taking Tylenol 500 mg tablets 1-2 tablets by mouth as needed for pain and Docusate 100 mg tablets, 2 tablets by mouth daily for constipation. Both of these medications are not on the hospice medication list. RN #1 verified the findings at the observation visit on 01/14/25.”

“Based on chart review, review of Interdisciplinary Group (IDG) notes, and interview, the hospice failed to follow the patient’s Plan of Care (POC) regarding Medical Social Worker (MSW) and Home Health Aide (HHA) visit schedules for 6 out of 14 patients (Patient #4, #5, #7, #9, #12 and #14). The findings include: Review of Patient #4 medical record on 01/15/25 at 10:50 AM showed Start of Care (SOC) on 01/04/25 with HHA visits 2 visits for 1 week then 3 visits for 11 weeks. HHA visits are documented on 01/08/25 and 01/13/25. This does not follow the POC and there is no documentation in the chart to explain any circumstances. During chart review on 01/16/25 at 11:05 AM, Branch Manager is unable to find documentation and verifies the finding. Review of Patient #5s medical record on 01/15/25 at 11:30 AM showed SOC on 10/15/24 with HHA visits 2 visits per 1 week then 5 visits for 12 weeks. The week of 12/21/24 there is no visit on 12/25/24 and no documentation for a missed visit. During chart review on 01/16/25 at 11:15 AM, Branch Manager is unable to find documentation and verifies the finding. Review of Patient #7s medical record on 01/15/25 at 12:05 PM showed SOC on 01/08/25. There are no orders for MSW to perform an assessment visit. During chart review on 01/16/25 at 11:15 AM, Branch Manager is unable to find documentation and verifies the finding. Review of Patient #9s medical record on 01/15/25 at 12:50 PM showed SOC on 12/28/24. SN visits are scheduled as 3 visits for 1 week then 2 visits a week for 12 weeks. Week starting 01/04/25 has 1 visit by SN on 01/09/25 with no documentation for missed visit by RN that week. During chart review on 01/16/25 at 11:10 AM, Branch Manager is unable to find documentation and verifies the finding. Review of Patient #12s medical record on 01/15/25 at 2:08 PM showed SOC on 08/27/24. There are no orders for MSW to perform an assessment visit. MSW visit documented on 08/28/24. HHA visits are scheduled for 1 visit for 1 week then 2 visits a week for 12 weeks. HHA visit documented on 09/24/24 and no second visit documented that week. During chart review on 01/16/25 at 11:35 AM, Branch Manager is unable to find documentation and verifies the finding. Review of Patient #14s medical record on 01/15/25 at 2:28 PM showed SOC on 12/09/23. HHA visits are scheduled for 2 visits a week for 13 weeks. There are no documented HHA visits in the medical record. There is no documentation in the medical record why HHA visits were not completed. During chart review on 01/16/25 at 11:26 AM, Branch Manager is unable to find documentation and verifies the finding.”

“Based on observations, interview, and review of the hospice policy entitled “;Equipment/Supply Bag Techniques”, the hospice staff failed to follow standards of practice for infection control by 1 of 1 Hospice Home Aide (HA #1) and 2 of 2 Registered Nurses (RN#1, RN #2) for 3 of 3 applicable patients (Patients #1, #2 and #3). Record Review of the facilitys policy entitled “;Equipment/Supply Bag Techniques” dated 2022 showed that the floor is considered a “;dirty” area and equipment should be retrieved from the supply bag after handwashing and placed on a clean surface. The findings include: Observation during Patient #1s home visit on 01/14/25 at 9:15 AM showed HHA entering patients home wearing gloves and only removing same gloves at the end of the visit. During an interview on 01/14/25 at 9:45 AM, HHA #1 stated that he/she thought she had exchanged gloves inside patients home in the kitchen.Observations during Patient #2s home visit on 01/14/25 at 10:45 AM showed RN #2 placed clean barrier on floor, performed hand hygiene, donned gloves and reached into equipment bag to retrieve supplies. RN #2 used a retractable measuring tape to acquire measurements of patients right upper arm circumference then retracted the tape without first sanitizing the extended tape. RN #2 was observed reaching into equipment bag with gloved hand 2 times without removing used gloves and performing hand hygiene and reaching into equipment bag 3 times with ungloved, non-sanitized hands to retrieve equipment. During an interview on 01/16/25 at 10:45 AM, the Branch Manager reported the finding does not follow hospice policy or best standards of practice for infection control. Observation during Patient #3s home visit on 01/14/25 at 12:30 PM showed RN #1 after using stethoscope to assess patient, place stethoscope under right arm without sanitizing the stethoscope first. During an interview on 01/14/25 at 1 PM, RN #1 stated that this was not a good practice and should have sanitized the equipment after use.”

“Based on observation and medical record review, the hospice Registered Nurse (RN) failed to provide individualized, specific, detailed instructions for the Home Health Aide (HHA) to follow when delivering patient care for 6 out of 10 patients (Patient #1, #3, #4, #6, #10 and #14). Findings include Observation visit for Patient #1 on 01/14/25 at 9:15 AM showed HHA Plan of Care (POC) with instructions to “;Make bed/change linens and Shaving” which HHA did not perform. Surveyor asked why these tasks were not performed and HHA stated that caregiver/spouse always does those tasks. HHA assignment also list for Bathing/personal hygiene: Complete Bath/Tub/Shower. This is not a clear, specific individualized instruction for the HHA to follow. Patient #1 Start of Care is 03/07/24 and HHA POC documents “;current aide plan effective 03/08/24”. There has been no update of Patient #1s HHA assignment since SOC and caregiver is performing some tasks. Patient #1 is also a high fall risk. There is no documentation on the HHA POC to indicate this. During an interview on 01/16/25, Branch Manager stated that the HHA POC should have been updated by the RN and more individualized. Observation visit for Patient #3 on 01/14/25 at 12:30 PM showed HHA assignment lists for Bathing/personal hygiene: Complete Bath/Tub/Shower. This is not a clear, specific individualized instruction for the HHA to follow. Patient #3 is also a high fall risk, there is no documentation on the HHA POC to indicate this. During an interview on 01/16/25, Branch Manager stated that the HHA POC should have been updated by the RN and more individualized. Review of Patient #4s medical record on 1/15/25 at 10:50 AM showed SOC on 01/04/25 with HHA visit schedule 2 visits for 1 week then 3 visits per week for 11 weeks. Patient is a high risk for falls, there is no documentation on the HHA POC to indicate this. HHA visit documentation for 01/08/25 and 01/13/25 document no care from the HHA and no indication why care was not performed. During an interview on 01/16/25 at 11:05 AM, Branch Manager stated that the HHA should have documented why care was not completed and notified the RN. Review of Patient #6s medical record on 1/15/25 at 11:30 AM showed SOC on 10/15/24 with HHA visit schedule 2 visits for 1 week then 5 visits per week for 12 weeks. Patient has diagnosis of Chronic Obstructive Pulmonary Disease and uses oxygen in the home but there is no documentation on the HHA assignment to indicate oxygen precautions. During an interview on 01/16/25 at 11:15 AM, Branch Manager stated that the RN should have added oxygen precautions on the assignment. Review of Patient #10s medical record on 1/15/25 at 1:10 PM showed SOC on 11/19/24 with HHA visit schedule 2 visits for 1 week then 2 visits per week for 12 weeks. HHA Assignment showed HHA lists for Bathing/personal hygiene: Complete Bath/Tub/Shower. This is not a clear, specific individualized instruction for the HHA to follow. During an interview on 01/16/25 at 11:20 AM, Branch Manager stated that the HHA POC should have been updated by the RN and more individualized. Review of Patient #13s medical record on 1/15/25 at 1:55 PM showed SOC on 05/24/24 with HHA visit schedule 5 visits for 12 weeks. HHA Assignment showed HHA lists for Bathing/personal hygiene: Complete Bath/Tub/Shower. This is not a clear, specific individualized instruction for the HHA to follow. During an interview on 01/16/25 at 11:21 AM, Branch Manager stated that the HHA POC should have been updated by the RN and more individualized.”

“Based on chart review and interview, the hospice failed to provide documentation when patients revoke hospice care that the patients provider and/or receiving facility was provided with a written discharge summary for 2 out of 2 patients (Patient #13 and #14). Findings include Review of Patient #13s medical record on 1/15/25 at 1:55 PM showed patient SOC on 05/24/24 and revocation of hospice on 07/29/24. There is no clear documentation that the discharge summary was sent to the receiving facility or provider. During chart review on 01/16/25 at 11:21 AM, Branch Manager was unable to find documentation. Review of Patient #14s medical record on 1/15/25 at 2:28 PM showed patient SOC on 12/09/23 and revocation of hospice on 01/02/24. There is no clear documentation that the discharge summary was sent to the receiving facility or provider. During chart review on 01/16/25 at 11:26 AM, Branch Manager was unable to find documentation.”