Carilion Hospice Services of Roanoke

“It is required that each patient’s individualized written plan of care 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 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that the individualized care plan identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 7: This pediatric patient elected the hospice benefit on 03/14/2026 with the diagnosis of end stage renal disease. The hospice plan of care was updated on 04/24/2026 to administer Renastep 300ml at 30 ml per hour for 20 hours daily and included an intervention to instruct the patient’s family regarding safe administration. The hospice registered nurse (RN) note dated 04/21/2026 documented that a G-Tube was placed on 04/21/2026 when the patient was transported to the emergency department and subsequently admitted for general inpatient hospice care. Review of the hospice plan of care for the dates of 04/21/2026-08/19/2026, revealed that the plan of care ordered enteral nutrition but did not address the newly placed G-tube, including size and type of tube or the care and management required for the G-tube. In an interview with the Clinical Nurse Manager on 08/18/2026, it was stated that there was no size or documentation of the type or care for the G-tube noted in the clinical record. CLINICAL RECORD 18: This patient elected the hospice benefit on 11/05/2025 with a terminal diagnosis of Alzheimer’s Disease. The RN initial comprehensive assessment dated 11/05/2025 documented a Palliative Performance Scale (PPS) of 20%, slight nausea and slight agitation. The patient’s date of death was 11/15/2026. Review of the hospice plan of care for the dates of 11/05/2026-11/15/2025, the date of the patient’s death, did not identify goals, interventions, or other care planning to address the patient’s end of life needs. During joint clinical review and interview on 08/19/2026, it was stated that the plan of care did not include all interventions needed based upon the assessments of the patients.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that the sharing of information occurred between all disciplines providing care and services in all settings. CLINICAL RECORD 6: This patient elected the hospice benefit on 08/14/2026 with a terminal diagnosis of incarcerated inguinal hernia and was admitted to general inpatient (GIP) hospice care on this date at a hospital. The hospice plan of care for the dates of 08/14/2026-08/19/2026 revealed that the hospice plan of care identified a vascular access device and directed the skilled nurse to change the vascular access dressing per protocol. The plan of care stated, “Hospice and facility staff will collaborate to provide optimal end-of-life care”, however, the plan of care did not clearly identify the respective responsibilities of the hospice and hospital staff for the care of the vascular access device. There was no documented evidence that the hospice coordinated with the hospital regarding the care and responsibilities of the vascular access device. During joint clinical review and interview on 08/19/2026, the clinical nurse manager stated, “the clinical records did not include clear documentation for the sharing of information and responsibilities of the different providers”.”

“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. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 4 (25%) home visits conducted it was revealed that the hospice did not ensure that the staff followed 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. DOCUMENT 1: Agency Policy titled, Hand Hygiene, original date 12/2018 and effective date 06/2026, stated in part, “Cleanse hands BEFORE: a. direct contact with patients or their surroundings, even if gloves will be worn. b. donning gloves...”. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 04/22/2026 with a terminal diagnosis of Lewy Body Dementia. The patient resided in an assisted living facility (ALF). The home visit was observed with the hospice aide (Personnel Record 1) on 08/18/2026. The Hospice RN was in attendance. The hospice aide was observed sanitizing hands and putting on gloves and assisting the patient from his wheelchair to the toilet for a toilet bath. The hospice aide reached around the bathroom door to a shelf to obtain supplies. The hospice aide removed the patient’s clothing and placed a towel around the patient. The hospice aide then cleaned the patient’s face, upper body, and lower body. She shampooed the patient’s hair. The hospice aide removed the patient’s shoes and placed a towel under the patient’s feet. The hospice aide did not change her gloves after removing the patient’s shoes. Following the cleansing and drying of the patient’s feet, the hospice aide pushed her hair back from her face with her gloved hand and continued to provide care without sanitizing her hands and changing gloves. The hospice aide then informed the patient that she was going to wash his buttocks and changed the water in the basin at the sink. She assisted the patient to stand up and cleansed the patient’s perineal/rectal area. The hospice aide continued to wear the same gloves. The hospice aide removed crumbs from the patient’s wheelchair and placed the patient in the wheelchair. She then stated that she needed to go out of the room to get sheets for the patient’s bed. She removed her gloves before leaving but did not sanitize her hands. Upon returning from obtaining the sheets, the hospice aide donned a new pair of gloves without sanitizing her hands. The Clinical Nurse Manager (Personnel Record 5) was interviewed on 08/18/2026 and stated that the hospice aide practice did not comply with the agency’s policy for hand hygiene and glove use. The Clinical Nurse Manager stated that the hospice aide would receive re-education regarding proper hand hygiene and glove use.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse 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 and interview. In 2 of 10 (20%) clinical records reviewed in which hospice aide services were provided it was revealed that the agency did not ensure that the written patient care instructions provided to the hospice aide were clear and specific. CLINICAL RECORD 1: This patient elected the hospice benefit on 04/22/2026 with a terminal diagnosis of Lewy Body Dementia. The hospice plan of care for the benefit period dated 04/22/2026-08/19/2026 included orders for the hospice aide visits one time a week (1XW) and was increased on 08/16/2026 to hospice aide visits two times a week (2XW). Review of the hospice aide care plan for the dates of 07/28/2026-08/15/2026 instructed the hospice aide to provide a partial/complete bed bath. The instruction did not clearly identify whether the hospice aide was to provide a partial bed bath or a complete bed bath. CLINICAL RECORD 14: This patient elected the hospice benefit on 08/03/2026 with a terminal diagnosis of oropharyngeal dysphagia. The hospice plan of care for the benefit period dated 08/03/2026-11/01/2026 included orders for hospice aide visits two times a week (2XW) and identified safety/teaching interventions related to the patient’s aspiration risk. The RN initial comprehensive assessment completed 08/03/2026 documented that the patient experienced choking with eating. Review of the hospice aide care plan for the dates of 08/03/2026-08/19/2026 revealed no instructions directing the hospice aide regarding aspiration precautions or safety measures. A joint review of clinical records and interview was conducted with the RN Clinical Manager on 08/20/2026, It was stated that the hospice aide care plans did not include clear and complete instructions to the hospice aide to address the needs of the patient.”

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the expiration date. This standard was not met as evidenced by interview and observation which revealed the hospice agency did not ensure that medical supplies were all monitored for expiration dates and removed from the available inventory when expired. During observation of the hospice supply room on 08/20/2026, conducted with the Clinical Nurse Manager, a vial of sterile water, 10ml was observed on the shelf in the supply room with an expiration date of 05/01/2026. The expired sterile water had remained in the hospice supply room and was available for use. The Clinical Nurse Manager was present during the observation of the supply room and stated that the normal saline vial was expired and removed the expired normal saline vial from the inventory. This hospice agency did not ensure that medical supplies were all monitored for expiration dates and removed from the available inventory when expired. During observation of the hospice supply room on 08/20/2026, conducted with the Clinical Nurse Manager, a vial of sterile water, 10ml was observed on the shelf in the supply room with an expiration date of 05/01/2026, which had expired 111 days prior to observation. The expired sterile water had remained in the hospice supply room and was available for use. The Clinical Nurse Manager was present during the observation of the supply room and stated that the normal saline vial was expired and removed the expired normal saline vial from the inventory.”

“Observed in Record Review. In 16 of 16 patient records reviewed, it was noted that the hospice organization was using a three page standing orders document for all patients that were not consistent with assessed clinical needs. For example, the standing orders included 18 different symptoms with multiple corresponding medications, treatments as well as care of infusion devices, wound care, urinary retention and caregiver crisis. Agency policy entitled Provider Orders stated that the provider can exclude any components of the standing orders however there were none that were excluded. This was discussed with hospice leaders.”

“Observed in Tracer Activities. The organization did not have a policy that addresses/defines the assessment of bereavement needs. There was nothing defining the services that would be provided based on the assessment. In 3 of 3 bereavement records reviewed, there were no documented initial bereavement risk assessments that outlined the patients’ bereavement needs. The hospice manager and the bereavement coordinator were present during the review and observed the same. Observed in Record Review. In 16 of 16 patient records reviewed, it was noted that a pre death bereavement assessment was not conducted as stated in agency policy entitled Bereavement Assessment Process. For example, during the initial nursing assessment a Bereavement Risk Assessment/Complications and Risk Factors form listing triggers that would necessitate a face to face bereavement assessment by the Bereavement Coordinator was completed. However, even in records that indicated triggers were identified there was no bereavement assessment completed by the Bereavement Coordinator. For example, in record review #4, a pediatric hospice patient there was no formal bereavement assessment completed. In another record review for hospice home visit #4 there were several triggers identified including lack of social support, financial concerns and job-related stress however there was no formal bereavement assessment completed. In another example, in hospice record review #3, multiple triggers were identified including loss of other parent in the last six months and multiple losses of family members in the past two years however there was no formal bereavement assessment done. In all other records there was documentation in the initial IDT notes that bereavement was assessed as low or medium but there was no documentation of a numerical score or any parameters to define grief levels. In another example in hospice record review #8 there was documentation in the record that the patient had found his wife following a suicide 29 years ago and had suffered anxiety and depression since then. There was no check mark to indicate that a face to face assessment should occur although mental health concerns were listed as a particular trigger. In another example, in record review #7 documentation in the IDT note indicated that the wife was at a moderate bereavement risk due to the loss of her brother six months ago however SN did not document this a trigger and there was no documentation that a face to face assessment was indicated. This was discussed with hospice leadership.”

“Observed in Record Review. In 4 of 16 patient records reviewed, it was noted that the stated goals on the plan of care were not measurable. For example, in record review for hospice home visit #1 one goal was stated as pt/cg will verbalize how to care for cardiac disease process. In the same record there was no goals stated for oxygen education. In record review #4 another example of a goal that was not measurable or timed was stated as Caregiver distress will be decreased and be able to express grief. In another example, in record review #9 a goal for Coping Issues was stated as Pt/Caregiver will demonstrate healthy attributes of effective coping by the end of the certification period. In record review #8 the following goal was stated for Liver Disease, pt. will verbalize understanding of and strategies to manage liver disease by verbalizing appropriate diet and med compliance. The goal was not timed. This was discussed with the Hospice Clinical Team Leader assisting with record reviews.”

“Observed in Record Review. In 5 of 16 patient records reviewed, it was noted that there was no frequency for volunteer services involving the visitation of the hospice choir to patient homes. This was noted in hospice record reviews for home visit #2 and #3. In record review #2, there were no orders for frequency on the hospice plan of care for music therapy visits. In record review for hospice home visit #4 and hospice record review #1 it was noted that the plan of care did not contain planned visit frequencies for MSW and the monthly visits were entered on an individual visit by visit basis. This was reviewed with hospice leadership.”

“Observed in Record Review. In 1 of 4 home visits conducted, an RN was observed performing a point of care PT/INR during hospice home visit #2. There were no orders on the plan of care for this treatment. This was confirmed by Hospice director and Hospice Clinical Team Leader. Observed in Record Review. In 6 of 16 patient records reviewed, it was noted in record review for hospice home visit #3 that the current order for Gabapentin was not what the patient was taking although the documentation indicated that the staff was aware that the patient was taking a different dosage. Gabapentin 200 mg BID was ordered on the plan of care but the patient had told the nurse that she was taking Gabapentin 300 mg BID. In another example, in record review for hospice home visit #2 there were no orders to discontinue multiple oral medications as well as two types of insulin. The nurse stated that the patient had chosen to stop taking the medications and insulin three weeks ago. Additionally for this patient there was no location for Voltaren gel to be applied and was stated as apply to affected areas and no location for Nystatin apply externally was the only indication. Additionally, there was no order to discontinue Levaquin which the patient refused to take after multiple doses caused her nausea. In another example, in record review for hospice home visit #4, Dexamethasone was not stated as a PRN medication however it was not being given daily as stated. In another example, in review of record for hospice home visit #1, Oxycodone was ordered for pain with no indication for pain level. In record reviews for hospice home visits #1, 2, 3, and 4 all oxygen orders were stated in ranges from 3-5 L to 4-10 L with no indication for titration. In record review for hospice home visit #4 there were no orders to discontinue Humira and aspirin which were not given after the patient had a nose bleed and an ear bleed. In hospice record review #4 it was noted that there were no orders for new medication Trazadone which was added to the medication list and the standing order used to insert a foley catheter lacked the balloon size. In record review #8 there were no orders for how often the patient was to monitor blood glucose and no parameters for holding insulin. The order was for 3 units of Humulog Insulin in the morning, at noon, at dinner and Lantus Insulin at HS. Additionally for this patient there was an intervention to apply heat for pain no longer than 20 minutes but no location was stated and the patient had multiple areas of pain including shoulder, leg and scrotum. This was discussed with the Hospice Clinical Team Leader assisting with record reviews.”

“Observed in Record Review. In 3 of 16 patient records reviewed, it was noted that the hospice plan of care was not updated. For example, in review of record for hospice home visit #1 a problem entitled, hospice orientation entered by the MSW had not been met and the patient had been on services for over 1 year. In another example, in record review #10 it was noted that a goal related to teaching enteral feeding was met and achieved one month after start of care however, the plan of care was not updated and this remained an open issue 7 months later. In another example, in record review #9, the plan of care indicated that the patient had Enteral Feedings with stated goals that referenced diarrhea and pain however, the patient was not receiving enteral nutrition therapy and had not been revised or corrected for three months. This was discussed with the Hospice Clinical Team Leader.”

“Observed in Record Review. In 2 of 16 patient records reviewed, it was noted that surveillance activities were not implemented. For example, in review of record for hospice home visit #3 the patient had a positive stool culture for C-diff. There was no infection report documented. In another example, in hospice record review for hospice home visit #2 the patient was treated for an upper respiratory infection and no infection report was documented. This was reviewed and confirmed by hospice leadership. Observed in Patient Home. In 1 of 4 patient records reviewed, it was noted in hospice visit #3 that following patient use, the nurse cleansed her equipment and placed them back onto the same barrier to dry. This was observed by the Hospice Clinical Team Leader present during the visit.”