Custom Care Hospice

“Based on record review and interview, the hospice failed to include in the Plan of Care all services necessary to meet the palliation and management of the patient’s terminal illness and related condition, including drugs and treatments, in that the Plan of Care did not include taping a magnet over the patient’s Automatic (Implanted) Cardiac Defibrillator (battery-powered device placed under the skin with wires implanted in the heart to detect and stop fatal heart rhythms by delivery of electric shocks) to deactivate the defibrillator to not shock the patient for 1 (Patient #3) of 4 patient records reviewed with the diagnosis of End-Stage Heart Failure (severe stage where heart is too weak to pump sufficient blood) as the terminal diagnosis. The failure placed the patient at risk of pain, increased anxiety and stress, and the patient’s family at risk of increased anxiety and stress. Patient #3:Record review of Patient #3’s clinical record revealed a Plan of Care dated 1/10/2025 to 4/9/2025. The Plan of Care indicated that Patient #3 started on the agency’s services on 1/10/2025. The Plan of Care listed End-Stage Heart Failure (severe stage where heart is too weak to pump sufficient blood) as the terminal diagnosis. The Plan of Listed Presence of Automatic (Implantable) Cardiac Defibrillator as a secondary diagnosis. Registered Nurse I conducted a skilled nurse visit on 2/6/2025. Registered Nurse I documented that Patient #3 was in decline, crisis care was started, and a magnet was taped over Patient #3’s defibrillator to deactivate it. The Plan of Care did not include taping a magnet over Patient #3’s defibrillator to deactivate it. Review of the agency’s policy titled “The Plan of Care policy number 2-044” revised November 2024, read in part; “Purpose To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...Procedure...4. The plan of care will identify the patient’s needs and services to meet those needs...12. The written plan of care will contain, but will not be limited to, the following...M. Individualized interventions to assist with the end-of-life care...R. Drugs, biologicals and treatments...” During an interview on 2/10/2026 at 2:10 PM with the Supervising Nurse, Alternate Administrator, and the Clinical Manager, the surveyor discussed that Patient #3’s Plan of Care did not include taping a magnet over Patient #3’s defibrillator. The surveyor asked what would prompt the nurse to tape a magnet over the defibrillator. The Supervising Nurse informed the surveyor that the nurse would have an order from the physician to do that. The Supervising Nurse stated, “Would do it when they (patient) started to transition (showing signs that death would be within a few hours to a few days).” During an interview on 2/12/2026 at 11:33 AM with Registered Nurse I, the surveyor discussed the defibrillator being taped over Patient #3’s defibrillator and that it was not included in the Plan of Care. Registered Nurse I informed the surveyor that the physician had instructed Registered Nurse I to tape a magnet over Patient #3’s defibrillator. Registered Nurse I stated, “(Patient #3) was starting on crisis care. I feel like I wrote an order.” Review of the agency’s policy titled “The Plan of Care policy number 2-044” read in part; “Purpose To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...Procedure...4. The plan of care will identify the patient’s needs and services to meet those needs...12. The written plan of care will contain, but will not be limited to, the following...M. Individualized interventions to assist with the end-of-life care...R. Drugs, biologicals and treatments...” Review of the agency’s policy/procedure titled “Implantable Cardioverter-defibrillator Deactivation, Home Care,” reviewed on 9/14/2025, read in part; “...In emergent situations (such as when a patient is receiving repetitive painful shocks) and with a practitioner’s verbal order, a nurse may deactivate an ICD (Implantable Cardioverter-Defibrillator) using a magnet...””

“Based on record review, interview, and observation, the registered nurse responsible for the supervision of the aide, failed to prepare written care instructions for the aide to include that a patient was to be transferred via a lift (mechanical patient lift designed to safely transfer an individual with limited mobility between beds, chairs, toilets, and bathing surfaces) in 1 (Patient #6) of 3 home visits to patients that resided in a skilled nursing facility. The failure placed the patient at risk of injury. Patient #6:Record review of Patient #6’s clinical record revealed a Plan of Care dated 11/6/2025 to 1/4/2026. The Plan of Care listed Senile Degeneration of the Brain (decline in memory, behavior, thinking, learning, and understanding) as the terminal diagnosis. The Plan of Care contained orders for Patient #6 to receive skilled nursing visits once a week and hospice aide visits 5 times a week. Patient #6’s clinical record contained a hospice Aide Care Plan dated 11/6/2025 to 1/4/2026. The Aide Care Plan indicated that Patient #6 started on the agency’s services on 1/10/2025. The Aide Care Plan indicated that the Aide Care Plan, dated 11/6/2025 to 1/4/2026, had been effective since 1/10/2025. The Aide Care Plan listed ‘Transfer Client from Bed/Chair” and “Transfer Client from Chair/Bed” every visit as tasks for the hospice aide to perform. The Aide Care Plan did not include that the hospice aide to was to transfer Patient #6 with a mechanical lift. Registered Nurse C conducted a recertification comprehensive assessment on 12/11/2025. Registered Nurse C documented that Patient #6 was transferred from bed to chair/chair to bed with maximal assistance. Hospice Aide F conducted a hospice aide visit on 12/11/2025. Hospice Aide F documented transferring Patient #6. Hospice Aide G conducted a hospice aide visit on 12/16/2025. Hospice Aide G documented transferring Patient #6. Hospice Aide F conducted a hospice aide visit on 12/17/2025. Hospice Aide F documented transferring Patient #6. Hospice Aide F conducted a hospice aide visit on 12/19/2025. Hospice Aide F documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/22/2025. Hospice Aide D documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/23/2025. Hospice Aide D documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/24/20205. Hospice Aide D documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/26/2025. Hospice Aide D documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/29/2025. Hospice Aide D documented transferring Patient #6. Hospice Aide D conducted a hospice aide visit on 12/30/2025. Hospice Aide D documented transferring Patient #6. Hospice Aide H conducted a hospice aide visit on 12/31/2025. Hospice Aide H documented transferring Patient #6. During a home visit with concurrent interviews with hospice staff and facility staff on 2/10/2026 at 9:50 AM to Patient #6, the surveyor asked Registered Nurse C how Patient #6 was transferred by the hospice aide. Registered Nurse C stated, “A lift.” The surveyor asked Registered Nurse C if the lift was included in the Aide Care Plan. Registered Nurse C stated, “I am not sure but I will look.” The surveyor asked Hospice Aide D was Patient #6 to be transferred by a lift. Hospice Aide D stated, “Yes.” The surveyor asked Facility Licensed Vocational Nurse E how Patient #6 was transferred from bed/chair and back. Facility Licensed Vocation Nurse E stated, “We use a lift to transfer.” Facility Licensed Vocational Nurse E gave the surveyor a document titled “Task List Report.” The Task List Report read, “Resident requires a lift for all transfers with assist of 2 staff members” with 11/14/2025 listed as the initiation date. The surveyor observed Patient #6 in a reclining chair with a lift sling underneath Patient #6. During an interview on 2/10/2026 at 2:10 PM with the Supervising Nurse, the Alternate Administrator, and the Clinical Manager, the surveyor discussed the aide care plan did not include how the aide was supposed to transfer the Patient #6. Patient #6 required a lift for transfers. The Clinical Manager stated that the aide care plan listed that Patient #6 was to be transferred by lift with two-person assist. The surveyor asked when the aide care plan had been updated. The Clinical Manager informed the surveyor that it was updated on February 10, 2026. The surveyor discussed that the aide care plan did not specify how to transfer Patient #6 prior to the home visit conducted on 2/10/2026. The surveyor asked how this could affect the agency’s patients. The Supervising Nurse stated, “It would be a big safety risk.” During an interview on 2/12/2026 at 11:19 AM with Registered Nurse C, the surveyor asked Registered Nurse C was the lift on the aide care plan when the surveyor had asked Registered Nurse C on 2/10/2026. Registered Nurse C stated, “No, it was not. I updated it that day.” The surveyor asked who would be responsible for updating the Aide Care Plan and updating the Aide Care Plan at the facility. Registered Nurse C informed the surveyor that Registered Nurse C would be responsible for updating the Aide Care Plan and the Aide Care Plan at the facility. Review of the agency’s policy titled “Hospice Aide Services Policy Number 2-006” revised November 2024, read in part; “Purpose To specify the role of the hospice aide and/or homemaker in hospice care. Policy...Hospice aide services may be included for routine care on an intermittent basis when personal care is needed. Services provided by an aide include bathing, shampoo, range of motion activities, dry dressing changes, assisting the patient to the bathroom, use of commode or bed, assisting with meal preparation, feeding the patient, light housekeeping and/or linen changes. These activities, in accordance with the interdisciplinary plan of care and physician’s (or other licensed practitioner’s) orders, will be assigned and supervised by a hospice registered nurse...Procedure 1. The need for hospice aide services will be identified and ordered by the interdisciplinary group...4. Hospice aide patient care instructions will be written by the Registered Nurse who is a member of the interdisciplinary group and who is responsible for supervision...””

“Based on record review and interview, the agency failed to include in the clinical record a physician order to tape a magnet over a patient’s Automatic (Implantable) Cardiac Defibrillator (battery-powered device placed under the skin with wires implanted in the heart to detect and stop fatal heart rhythms by delivery of electric shocks) to deactivate it in 1 (Patient #3) of 4 patient records reviewed with a diagnosis of End-Stage Heart Failure (severe stage where heart is too weak to pump sufficient blood). The failure placed the patient at risk of pain, increased anxiety and stress, and the patient’s family at risk of increased anxiety and stress. Patient #3:Record review of Patient #3’s client record revealed a Plan of Care dated 1/10/2025 to 4/9/2025. The Plan of Care indicated that Patient #3 started on the agency’s services on 1/10/2025. The Plan of Care listed End-Stage Heart Failure (severe stage where heart is too weak to pump sufficient blood) as the terminal diagnosis. The Plan of Listed Presence of Automatic (Implantable) Cardiac Defibrillator as a secondary diagnosis. Registered Nurse I conducted a skilled nurse visit on 2/6/2025. Registered Nurse I documented that Patient #3 was in decline, crisis care was started, and a magnet was taped over Patient #3’s defibrillator to deactivate it. Patient #3’s clinical record did not contain a physician order to tape a magnet over Patient #3’s defibrillator to deactivate it. During an interview on 2/10/2026 at 2:10 PM with the Supervising Nurse, Alternate Administrator, and the Clinical Manager, the surveyor discussed that there was no physician’s order in Patient #3’s clinical record to tape a magnet over Patient #3’s defibrillator to deactivate it. The surveyor asked what would prompt the nurse to tape a magnet over the defibrillator. The Supervising Nurse informed the surveyor that the nurse would have an order from the physician to do that. The Supervising Nurse stated, “They (nursing staff) would do it (place magnet over defibrillator) when they (patient) started to transition (showing signs that death would be within a few hours to a few days).” During an interview on 2/12/2026 at 11:33 AM with Registered Nurse I, the surveyor discussed the defibrillator being taped over Client #3’s defibrillator and that there was no physician in Patient #3’s clinical record. Registered Nurse I informed the surveyor that the physician, Physician X, had instructed Registered Nurse I to tape a magnet over Patient #3’s defibrillator. Registered Nurse I stated, “(Patient #3) was starting on crisis care. I feel like I wrote an order.” Review of the agency’s policy titled “Verification of Physician Orders policy number 2-046” revised in November 2024, read in part; “Purpose To ensure that accurate physician (or other licensed practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. Policy Orders will be obtained from a licensed physician (or other licensed practitioner) for care and services to be provided to hospice patients...Procedure...2. Verbal orders will be documented...10. A copy of the order will be kept in the patient’s clinical record...””

“Based on record review and interview, the agency failed to include physician orders in the clinical records for 2 (#2, #3) of 2 clinical records reviewed where changes had been made to medications. The failure placed the patients at risk for omission of care or inappropriate care which could result in a negative outcome. Patient #2: Record review of Patient #2’s record revealed a Plan of Care dated 2/17/2024 to 4/26/2024. Patient #2’s record contained a “Client Medication Report” which listed Alzheimer’s Disease with Late Onset (progressive disease that could lead to not being able to respond to the environment) as the primary diagnosis. Registered Nurse D conducted a skilled nurse visit on 3/5/2024. Registered Nurse D documented that Lorazepam (used to treat anxiety) had been ordered. Patient #2’s clinical record did not contain a physician order for Lorazepam. During an interview on 3/15/2024 at 2:49 p.m. with Registered Nurse D, the surveyor asked about the order for Lorazepam. Registered Nurse D informed the surveyor that the Lorazepam was ordered by the physician. Registered Nurse D was asked the agency’s policy regarding physician orders. Registered Nurse D stated, “Write the order for the facility and put new orders in record.” When asked how it could impact a patient, Registered Nurse D stated, “it could have a great impact, especially if it wasn’t there.” Patient #3: Record review of Patient #3’s clinical record revealed a Plan of Care dated 2/21/2024 to 5/20/2024. The Plan of Care indicated that Patient #3 was admitted to the hospice’s services on 2/21/2024. The Plan of Care listed Cerebrovascular Disease (conditions that affect blood flow and the blood vessels in the brain) as the primary diagnosis. Patient #3’s Plan of Care contained on order for Oxygen (used to treat low blood oxygen levels) 2-4 liters per minute to be administered continuously. Record review of Patient #3’s clinical record revealed documentation by Hospice Registered Nurse C for 3/3/2024. Hospice Registered Nurse C documented: 8:55 a.m.: Hospice Registered Nurse C called Facility X and spoke to Facility Licensed Vocational Nurse D. Hospice Registered Nurse C documented that the facility nurse reported that Patient #3 refused breakfast and was not eating, oxygen saturation (measurement of hemoglobin bound to oxygen in the blood) was 90% while on oxygen at 3 liters per minute. Hospice Registered Nurse C instructed Facility Licensed Vocational Nurse D to increase Patient #3’s oxygen from 3 liters per minute to 5 liters per minute. Patient #3’s clinical record did not contain a physician order for Oxygen to be administered at 5 liters per minute. During an interview on 3/15/2024 at 4:34 p.m., record review, with the Alternate Administrator, Director of Nursing, Alternate Director of Nursing, and Director of Operations, the surveyor discussed that physician orders for changes in medications were not in the clinical records. The surveyor asked what was the policy regarding physician orders. The Director of Nursing stated, “The order is to be put in the same day or within 24 hours in the record.” During an interview on 3/18/2024 at 10:13 a.m. with Hospice Registered Nurse C, Hospice Registered Nurse C informed the surveyor that Hospice Registered Nurse C had instructed Facility Licensed Vocational Nurse to increase Patient #3’s oxygen from 3 liters per minute to 5 liters per minute. The surveyor asked who ordered the increase of oxygen from 3 liters to 5 liters and why there wasn’t a physician order in the clinical record. Hospice Registered Nurse C stated, “Because we have standing orders for Oxygen that is 2-5 liters per minute.” The agency had a policy titled “Verification of Physician Orders” that was labeled Policy No. 4-028.1 with a revision date of May 2023. The policy read in part; “Purpose To ensure that accurate physician (or other authorized independent practitioner) orders are obtained in accordance with applicable law and regulation. Policy...Verbal orders will be taken and documented only by professional, licensed hospice personnel...4. A copy of the physician’s or licensed independent practitioner’s order will be kept in the clinical record...””