Covenant 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, observation, and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure an accurate review of medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 05/16/2026 with a diagnosis of acute and chronic respiratory failure with hypoxia. During the home visit observation on 06/22/2026 with the Hospice Aide (HA) (Personnel Record 1), the HA was observed to give the patient a bed bath. The patient’s spouse put on a glove and applied zinc ointment to the patient’s coccyx area. The hospice drug profile and the home medication list did not include zinc oxide. The hospice drug profile was compared to the home medication list and the medications that the patient was currently taking. The hospice drug profile included Ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base) 3 ml nebulization solution inhalation 4 times a day. The home medication list included Ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base) 3 ml nebulization solution inhalation to be administered 2 times a day. The hospice drug profile included Spironolactone 25 mg tablets two tablets 2 times a day. The home medication list and the medication bottle was written as Spironolactone 100 mg cut in half two tablets twice a day. During a joint review of the hospice drug profile and the home medication list, the Clinical Manager, who was present during the home visit, stated that the Case Manager would correct the discrepancies in the patient’s medications.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure the drugs and treatments necessary to meet the needs of the patient were included in the written plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/16/2026 with a diagnosis of acute and chronic respiratory failure with hypoxia. Review of the skilled nurse note dated 06/15/2026 revealed that the patient had an abdominal stoma for a PleurX drain and the nurse performed wound care treatment for the stoma. The hospice plan of care was reviewed for the dates of 05/16/2026 to 06/23/2026 and did not include the interventions for the care of the abdominal stoma. During joint record review and interview on 06/25/2026, the Clinical Manager stated that the plan of care did not include interventions for the patient’s abdominal stoma care. The Clinical Manager stated further that the Registered Nurse Case Manager had been instructed to update the hospice plan of care to include appropriate stoma care interventions.”

“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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 2 of 6 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency Policy No. 7-009 Hand Hygiene, required in part: “Hand decontamination using an alcohol-based hand rub should be performed: A. before having direct contact with the patients. E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves.” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 05/16/2026 with a diagnosis of acute and chronic respiratory failure with hypoxia. During the home visit observation on 06/22/2026 with the Hospice Aide (HA) (Personnel Record 1), the HA was observed to provide a bed bath for the patient. The HA cleaned the patient’s perineal area with gloves on, then was observed to empty the water basin and proceeded to move the patient up in bad. The HA did not change gloves or sanitize hands after completion of the bath and before moving the patient up in the bed. CLINICAL RECORD 6/HOME VISIT 6: The patient elected the hospice benefit on 06/18/2026 with a terminal diagnosis of multiple myeloma with achieved remission. During the home visit observation on 06/23/2026 with the Registered Nurse (RN) (Personnel Record 6), the RN was observed to sanitize hands and don (apply) gloves, check a rash in the patient’s perineal area, and then took off gloves to check patient’s feet. The RN did not sanitize hands after taking off gloves and before assessing the patient’s feet. The Clinical Manager, who was present for the home visit, stated that the staff did not follow the hospice agency’s policy for hand hygiene.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. Agency Procedure “Wound Care: Assessment and Documentation,” revised 04/20/2026, required in part: “For Hospice patients, wound measurements are completed on admission visit, recert visit, and the first of each week.” CLINICAL RECORD 20: The patient elected the hospice benefit on 05/21/2026 with a terminal diagnosis of cerebral ischemia. The Registered Nurse (RN) documented on the comprehensive assessment dated 05/21/2026 the following wounds: coccyx wound stage 4, 2cmX6cmX0.2cm, undermining of 4 cm between 12 and 3 o’clock and a stage 1 right gluteal wound, 3cmX8cmX4.5cm with tunneling at 9 o’clock. The hospice plan of care dated 05/21/2026 to 08/18/2026 included orders for wound care. The skilled nurse (SN) visits from 05/25/2026 to 06/24/2026 were reviewed and there was no documented evidence that wound measurements were obtained. The SN visit note dated 06/03/2026 included documented that the patient’s wound care was completed by the facility wound care nurse. The SN visit note dated 06/12/2026 included documentation that the facility treatment nurse stated the wound to the coccyx was worse. The SN visit notes dated 06/16/2026 and 06/172026 included documentation that the facility wound care nurse completed wound care for these days. The SN note dated 06/19/2026 included documentation that the wound care was already performed. The SN visit notes dated 06/22/2026 and 06/24/2026 included documentation that wound care had been completed by the facility with no updates on wounds. The SN visit note dated 06/24/2026 included documentation that the Nurse Practitioner was notified of today’s assessment of the patient’s decline and orders were received to discontinue routine medications and start comfort medications. During a joint review and interview on 06/25/2026, the Clinical Manager stated that the nursing staff did not obtain wound measurements from the facility wound care nurse and therefore did not document the wound measurements in the hospice clinical record as per the agency policy.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) 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, observation, and interview. In 6 of 22 (27%) clinical records reviewed with hospice aide services provided, the agency did not ensure the written patient care instructions for the hospice aide were clear and complete. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/16/2026 with a terminal diagnosis of acute and chronic respiratory failure with hypoxia. The hospice plan of care dated 05/16/2026 to 08/13/2026 included orders for hospice aide visits 2XW (twice a week). The RN documented on the initial comprehensive assessment dated 05/16/2026 that the patient had a tracheo-cutaneous fistula/laryngectomy stoma and two pressure ulcers stage II to bilateral buttocks. The hospice aide care plan dated 05/16/2026 to 06/22/2026 did not include instructions for the aide related to the care or monitoring of the stoma and the pressure ulcers during personal care. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/08/2026 with a terminal diagnosis of pulmonary fibrosis. The RN documented on the initial comprehensive assessment dated 02/08/2026 that the patient had dysphagia (difficulty swallowing) and was on continuous oxygen at 4 liters per nasal cannula. The hospice aide care plan dated 02/08/2026 to 06/22/2026 did not include instructions to address dysphagia and oxygen safety requirements during personal care. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/14/2026 with a terminal diagnosis of cerebral ischemia. The hospice plan of care dated 05/14/2026 to 08/12/2026 included orders for hospice aide visits 1XW. The RN documented on the initial comprehensive assessment that the patient had an indwelling foley catheter attached to a drainage bag, was on continuous oxygen, and had wounds to bilateral feet and heels. The hospice aide care plan dated 05/14/2026 to 06/22/2026 did not include instructions for the care of the foley catheter, the dressings covering the wounds, and safety requirements for the oxygen. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/18/2026 with a terminal diagnosis of multiple myeloma. The hospice plan of care dated 06/18/2026 to 09/15/2026 included an order for hospice aide visits 1XW. The skilled nurse visit dated 06/23/2026 included documentation of a skin tear to the right elbow and a yeast rash in the groin area folds. The hospice aide care plan dated 06/18/2026 to 09/15/2026 did not include instructions for the management of care for the skin tear and rash during personal care. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/06/2026 with a terminal diagnosis of rheumatoid arthritis. The hospice plan of care dated 02/06/2026 to 05/07/2026 included safety measures, aspiration precautions, catheter precautions, clean technique, COPD (chronic obstructive pulmonary disease) precautions, and fall precautions. The hospice aide care plan dated 02/06/2026 to 05/07/2026 did not include precautions listed in the plan of care. The SN documented on the nursing visit dated 02/08/2026 an open area inside of knees stage 2 due to the catheter anchor. The hospice aide care plan dated 02/06/2026 to 05/07/2026 did not include precautions for management of catheter, wounds, safety, aspiration, and falls during personal care. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/03/2026 with a terminal diagnosis of COPD (chronic obstructive pulmonary disease). The hospice plan of care dated 06/03/2026 to 08/31/2026 included an order for hospice aide visits 1xW. The RN documented on the initial comprehensive assessment dated 06/03/2026 that the patient was administered oxygen. The hospice aide care plan dated 06/05/2026 to 08/31/2026 did not include directions for oxygen safety during personal care. During a joint clinical review and interview on 06/25/2026, the Clinical Manager stated that the hospice aide care plans needed to be more specific and a re-education would be provided to the RN staff.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 21: The patient elected the hospice benefit on 04/28/2026 with a terminal diagnosis of acute respiratory failure with hypoxia. The patient revoked the hospice benefit on 05/04/2026. The clinical record was reviewed and revealed that the agency did not ensure that a discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 22: This patient elected the hospice benefit on 02/10/2026 with a terminal diagnosis of ischemic cardiomyopathy and was discharged on 06/18/2026 for extended prognosis. The clinical record was reviewed and revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 23: This patient elected the hospice benefit on 03/24/2026 with a terminal diagnosis of cirrhosis of the liver. The patient revoked the hospice benefit on 05/11/2026. The clinical record was reviewed and revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. During an interview on 06/26/2026, the Director of Clinical Services stated that the policy of the agency was to fax the EMR (electronic medical record) discharge summary to the attending physician, but no evidence was present that proved faxes were sent.”