Transcend Hospice

“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. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 1: Agency Policy, Hand Hygiene and Compliance Program 5.7.1, last revised November 2019, stated in part, “Procedure: 1. Indications for hand hygiene are: before and after direct patient care, ... before re-entering nursing bag or patient’s clean supplies... 4. The proper procedure for handwashing when using soap and water is as follows: Turn water to a comfortable warm temperature. Hold hands under running water so they get completely wet. Lather hands well with liquid, antimicrobial soap: use friction; wash between fingers, wash area around and under nails. Using a clean paper towel, dry hands thoroughly. Turn off water faucet using towel. Discard paper towel in a disposable bag or waste can... 7. Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: I. Indications for handwashing and hand antisepsis:... B. No visible dirt, blood or body fluids on hands of HCW [health care worker] in the following clinical situation: Before direct patient contact. (IB) Recommended. After removing gloves (IB) Recommended. CDC Guidelines: (IA) Prefer alcohol hand rub or, alternately, (IB) antimicrobial soap and water.” HOME VISIT 3: During the home visit (Clinical Record 8) on 05/14/2025 with the Home Health Aide (HHA) (Staff 9), the HHA was observed washing the hands with soap and water. The HHA turned off the water with a dish towel that was hanging on a towel bar and then dried the hands with the towel. The HHA donned gloves and began the patient care. The HHA did not follow the Hand Hygiene and Compliance Program policy. During a document review and interview on 05/15/2025, the Clinical Manager confirmed that the staff did not follow the hand hygiene policy.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, it was noted that the documentation related to recruitment efforts included two separate flyers: one for the farthest geographical region and another for the area surrounding the main office. However, there was a lack of evidence demonstrating ongoing recruitment efforts. The primary recruitment for the office area was conducted through a web-based site, but there was no proof of volunteers being engaged in the region where the office is located. Additionally, the documentation did not provide any evidence of the effectiveness or tracking of the web-based recruitment efforts. No other recruitment activities were documented for either location. The Volunteer Coordinator (VC), who lived in the farthest region, focused her recruitment efforts there, while the recruitment around the main office relied heavily on Human Resources personnel for planning and implementation. During a documentation review and interview on 05/15/2025, the Volunteer Coordinator confirmed that most recruitment occurred in the farthest region. Although the VC resided in that area, she depended on the office staff for recruitment efforts in the main office’s location. During the same documentation review and interview, the Administrator acknowledged that the recruitment documentation was insufficient to demonstrate adequate efforts to support their volunteer program within their entire service area. Upon reviewing the volunteer program, the recruitment efforts documentation included two separate flyers used in the Atlanta (Texas) area, but lacked evidence of ongoing efforts. The recruitment efforts for the San Antonio area were conducted through VolunteerMatch. The documentation lacked proof of the effectiveness of VolunteerMatch. No other recruitment efforts were documented for either location. The Volunteer Coordinator (VC), who resided in the Atlanta area, conducted more recruitment efforts in that area. San Antonio’s recruitment efforts relied on the Human Resources personnel and the San Antonio Clinical Manager.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident:Hospice medication information. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visits for patients residing in a Skilled Nursing Facility (SNF), revealed the agency did not ensure the hospice medication information was provided to the SNF. HOME VISIT 1 (Clinical Record 5): The patient’s date of election was 02/27/2023. The Medication Profile dated 05/13/2025 revealed aspirin 81 mg tablet daily; Eliquis 5 mg tablet daily; loratadine 10 mg tablet daily; Lubricant Eye (PG-PEG 400) 0.4 %- 0.3 % drops three times daily; potassium chloride ER [extended release] 20 mEq [milliequivalents] daily; acetaminophen 500 mg tablet every eight hours PRN [as needed]; amlodipine 2.5 mg tablet daily; Colace 100 mg capsule twice daily; dextromethorphan-guaifenesin 10 mg- 100 mg/5 ml oral syrup every 4 hours as needed cough/congestion; ipratropium 0.5 mg- albuterol 3 mg (2.5 mg base)/3 mL nebulization soln [solution] every 6 hours as needed for congestion; lactulose 10 grams/15 mL oral solution TID [three times a day]; lactulose 10 grams/15 mL oral solution daily; losartan 50 mg tablet daily at bedtime; and Mucinex 600 mg tablet, extended release twice daily. During the Home Visit (Clinical Record 5) with the Registered Nurse (Personnel Record 6), the medication at the facility revealed acetaminophen 500 mg tablet every six hours PRN, dated 02/10/2025; Colace 100 mg capsule, one capsule once daily, dated 04/13/2025; Lubricant Eye (PG-PEG 400) 0.4 %- 0.3 % drops three times daily; Ciprofloxacin 250 mg tablet, one tablet daily for prophylactic, dated 03/16/2024; loperamide 2 mg capsule, one capsule prn diarrhea, dated 07/19/2022; dextromethorphan-guaifenesin 10 mg- 100 mg/5 ml oral syrup, give 10 mLs every 4 hours as needed cough/congestion; lorazepam oral concentrate 2 mg/ml, give 0.5 mg every two hours prn anxiety/agitation, dated 04/12/2025; Metamucil Oral Powder 28.3%, give one tsp [teaspoon] every 24 hours prn constipation, dated 08/19/2023; morphine sulfate oral solution 20 mg/ml, give 0.5 ml every two hours prn pain/SOB [shortness of breath], dated 04/12/2025; promethazine HCl 25 mg tablet every six hours prn nausea, dated 04/13/2025; acetaminophen 500 mg tablet, give two tablets every six hours prn pain/fever, dated 02/10/2022; acetaminophen rectal suppository 650 mg, give one suppository rectally prn fever, dated 04/13/2025. The facility’s medications did not include aspirin, Eliquis, potassium chloride ER, amlodipine, ipratropium-albuterol, lactulose, and Mucinex. The facility’s medication record revealed different instructions for acetaminophen and Colace. The agency’s medications did not include Ciprofloxacin, loperamide, lorazepam, morphine sulfate, Metamucil, acetaminophen suppository, and promethazine. The latest comprehensive assessment was dated 05/07/2025. The clinical record did not contain documented evidence supporting hospice medication information was provided to the SNF. HOME VISIT 2 (Clinical Record 6): The patient’s date of election was 03/28/2023. The Medication Profile dated 05/13/2025 revealed loperamide 2 mg oral tablet as needed diarrhea; acetaminophen 325 mg tablet every 6 hours as needed pain/fever; and Tylenol 325 mg tablet twice daily. During the Home Visit (Clinical Record 6) with the Medical Social Worker (Personnel Record 7), the medication at the facility revealed loperamide 2 mg oral tablet, give two tablets after the first loose stool then one tablet after each loose stool not to exceed four tablets in 24 hours for diarrhea; acetaminophen 325 mg tablet, give two tablets every 6 hours as needed pain/fever; and Tylenol 325 mg tablet, give two tablets twice daily. The latest comprehensive assessment was dated 05/07/2025.The clinical record did not contain documented evidence supporting hospice medication information was provided to the SNF. During a joint record review and interview on 05/15/2025, the Clinical Manager confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment or updated in the medication profile.”