Remarkable Hospice

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 8: The patient elected hospice care on 10/31/2024 with a diagnosis of hemiplegia following cerebral infarction. Skilled nursing visits were ordered and provided once (1) weekly beginning 10/31/2024. The skilled nursing (SN) visit dated 11/08/2024 documented, “Caregiver reports improvement with urine odor with prescribed antibiotics.” A physician order was entered on 11/08/2024 and read in part, “Cipro 500 mg 1 tablet 2 times daily oral for 7 days beginning 11/06/2024 Reason: UTI.” The Hospice Plan of Care, effective 10/31/2024 through 12/06/2024, did not document patient and family goals for the identified urinary tract infection. Clinical Record 10: The patient elected hospice care on 09/12/2024 with a diagnosis of hemiplegia following cerebral infarction. Skilled nursing visits were ordered and provided once (1) weekly beginning 09/12/2024. A physician order was entered on 11/01/2024 and read in part, “Macrobid 100mg capsule, one capsule 2 times daily oral Reason: UTI.” The Hospice Plan of Care, effective 09/12/2024 through 12/10/2024, did not document patient and family goals for the identified urinary tract infection. During the joint record review and interview on 05/07/2025, the Area Director confirmed that the plans of care did not include goals related to urinary tract infections.”

“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, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. Agency policy “Gloves” (review date 06/17/2024) stated in part, “Discard and replace disposable gloves as soon as feasible when contaminated or the function as a barrier has been compromised.” Agency Policy “Infection Prevention & Control in the Home Setting” (reviewed 06/17/2024) stated in part, “Hand hygiene shall be performed at a minimum... After contact with the patient or objects in the immediate vicinity of the patient... After removal of PPE, including gloves.” In 2 of 6 (33%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. Home Visit 2/Clinical Record 2: The patient elected hospice care on 02/22/2025 with a diagnosis of Alzheimer’s Disease. During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 05/07/2025, the HA provided a bed bath, including peri-care. After completing the bed bath, including peri-care, the HA dressed the patient, removed their gloves, and performed hand hygiene. The HA did not remove the contaminated gloves, perform hand hygiene, and don clean gloves after the bed bath, peri-care, and before dressing the patient. Home Visit 5/Clinical Record 20: The patient elected hospice care on 05/06/2023 with a diagnosis of Alzheimer’s Disease. During the home visit with the HA [Personnel Record 11] on 05/09/2025, the HA provided a bed bath. During the HA visit, the HA dropped the bottle of bath gel on the floor, picked up the bottle, removed their gloves, and donned a clean pair of gloves. The HA did not perform hand hygiene after removing and donning clean gloves per the agency policy. During an interview on 05/09/2025, the Area Director of Operations/Administrator) confirmed that hand hygiene should be performed between glove changes and that gloves should be discarded and replaced when they become contaminated.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Clinical Supervision and Guidelines” (revision date 05/31/2024) stated in part, “Visit patients receiving LVN/LPN service at least every 60 days for evaluation and supervision of the patient’s care unless otherwise specified by state regulation.” In 2 of 2 (100%) clinical records reviewed of patients who received Licensed Vocational Nurse (LVN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of Licensed Vocational Nurse (LVN) services per agency policy. Clinical Record 5: The patient elected hospice care on 07/31/2024 with a diagnosis of emphysema. The hospice recertification plan of care dated 01/27/2025 through 03/27/2025 ordered skilled nursing (SN) services once (1) weekly beginning 01/27/2025. The Licensed Vocational Nurse (LVN) completed nursing visits on 02/15/2025 and 02/16/2025. A clinical record review revealed no evidence that LVN supervisory visits were completed per agency policy between 02/15/2025 and 05/09/2025. Clinical Record 11: The patient elected hospice care on 02/08/2025 with a diagnosis of Alzheimer’s Disease. The hospice plan of care dated 02/08/2025 through 05/08/2025 ordered skilled nursing (SN) services twice (2) weekly beginning 02/08/2025. The Licensed Vocational Nurse completed a nursing visit on 02/17/2025. A clinical record review revealed no evidence that LVN supervisory visits were completed per agency policy between 02/08/2025 and 05/09/2025. In a joint record review and interview on 05/07/2025, the Area Director of Operations/Administrator confirmed that LVN supervisory visits were not completed per agency policy, every 60 days.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. and 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, interview, and observation. In 1 of 17 (6%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written care instructions to meet the patient’s needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 02/25/2025 with a diagnosis of Alzheimer’s Disease. The patient resided in a skilled nursing facility (SNF). The plan of care ordered HA services five (5) times weekly beginning the week of 02/25/2025. The HA care plan, effective 02/25/2025, assigned the HA the relevant task: shower every visit, ‘pt may have bed bath or refuse.’ The skilled nurse (SN) comprehensive assessment dated 02/25/2025 documented, “transfer with maximum assistance.” During the home visit with the HA [Personnel Record 2] on 05/07/2025, the HA was observed providing a bed bath to the patient. After the bed bath, the HA and a SNF staff member transferred the patient to a geri chair utilizing a gait belt. The HA care plan did not include specific care instructions, including how the patient was to be transferred and when the patient was to receive a shower or bed (patient unable to refuse due to cognitive abilities). During a joint record review and interview on 05/07/2025, the Area Director of Operations/Administrator confirmed the HA care plan did not include instructions from the Registered Nurse delineating when the patient was to receive a shower or a bed bath, and how to transfer the patient.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the agency’s “Volunteer Activity Report” with the Area Director of Operations/Administrator on 05/07/2025 revealed that volunteer utilization was 0.38% for 04/01/2024 through 03/31/2025. The Area Director of Operations/ Administrator confirmed the finding and stated, “It has been challenging to get volunteers at some of our ADS (alternate delivery sites).” During an interview on 05/07/2025, the Volunteer Coordinator/Office Manager [Personnel Record 8] confirmed that volunteer utilization was 0.38% and below the 5% requirement for 04/01/2024 through 03/31/2025 and stated, in part, “We have volunteers but not enough patients where they are willing to travel to.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”