Astria 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 and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 02/11/2025 for a diagnosis of Parkinson’s disease. The patient resided in an assisted living facility (ALF). During the home visit observation with the Hospice Aide (HA) (Personnel Record 7) on 04/15/2025, a medication review was completed by comparing the hospice medication profile, printed on 04/14/2025, to the ALF medication list, printed on 04/15/2025. The ALF medication list included the following medications that were not listed on the hospice medication profile: Vitamin B 12 1000 mcg, take 1 tablet by mouth daily, dated 07/02/2024; Morphine ER 15 mg, take one tablet by mouth twice daily, dated 02/07/2025; Vitamin D3 25 mcg, take 1 tablet by mouth daily, dated 05/28/2024; Acetaminophen 650 suppository, insert 1 rectally every 6 hours as needed for pain or fever, dated 02/12/2025; Bisacodyl 10 mg suppository, insert 1 rectally every day as needed for constipation, dated 02/12/2025; Calmoseptine, apply topically to affected areas as needed, date 02/11/2025; Haloperidol 2mg/ml, give 0.5 ml every 6 hours as needed for agitation, nausea or vomiting, dated 02/12/2025; Hyoscyamine 0.125 mg, give 1 tablet every four hours as needed for secretions, dated 02/12/2025; Lactulose 10gm/15ml, give 30 ml every 72 hours as needed for no bowel movement, dated 07/18/2024; Loperamide 2 mg, 1 capsule by mouth twice daily as needed for loose stool, dated 01/21/2025; Lorazepam 0.5 mg tablet, take 1 tablet every 6 hours as needed for anxiety, dated 02/12/2025; Morphine 100 mg/5 ml, give 0.25 ml (5mg) by mouth every 3 hours as needed for pain or shortness of breath, dated 02/12/2025; Oxycodone/APAP 5/325 mg, take 1 tablet every 6 hours as needed for pain, dated 04/07/2025; and Phenergan 10 mg, take 1 tablet every 6 hours as needed for nausea or vomiting, dated 02/12/2025. The hospice medication profile included the following medications that were not included on the ALF medication list: Melatonin 3 mg, take 1 tablet nightly as needed for insomnia, dated 02/12/2025; and Losartan 50 mg, take 1 tablet daily, dated 02/12/2025. Home Visit 2: The patient elected the hospice benefit on 01/15/2025 for a diagnosis of Alzheimer’s disease. The patient resided in an assisted living facility. During the home visit with the Registered Nurse (RN) (Personnel Record 4) on 04/15/2025, a medication review was completed by comparing the hospice medication profile, printed on 04/14/2025, to the ALF medication list, printed on 04/15/2025. The ALF medication list included the following medications that were not listed on the hospice medication profile: Athlete’s foot cream 1%, apply topically to affected area twice daily, dated 05/16/2024; Ensure liquid, give 1 can 1-2 times daily between meals, dated 08/06/2024; Lidocaine patch 5%, apply 1 patch topically to skin once daily for pain, leave on for 12 hours, dated 09/18/2024; Acetaminophen 650 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain dated 06/17/2024; Xanax 0.25 mg, take one tablet by mouth twice daily as needed for anxiety, dated 01/14/2025; GG/DM syrup 100/10/5, give 5 ml by mouth every 6 hours as needed for cough, dated 09/03/2024; Hydrocortisone 1%, apply topically to face four times daily as needed for rash, dated 07/01/2024; and Morphine 100 mg/5 ml, give 0.25 ml (5mg) by mouth every 3 hours as needed for pain or shortness of breath, dated 01/16/2025). The hospice medication profile included documentation the following medications that were not included on the ALF medication list: Haloperidol 5 mg, take 1 tablet every 6 hours as needed for agitation or restlessness, dated 01/15/2025. During joint clinical record review and interview on 04/16/2025, the Clinical Manager acknowledged that the medication lists had not been reconciled. She also commented that many of the medications listed on the ALF medication list and not on the hospice medication profile “were part of the hospice comfort kit and she was surprised to not see them on the hospice list.””

“It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by interview. The organization did not ensure the governing body assumed authority and responsibility for the organization’s ongoing performance improvement and patient safety program. During an interview on 04/16/2025 with the Chief Nursing Officer (CNO) a request was made for the organization’s governing body meeting minutes. The CNO stated there were no governing body meeting minutes for 2023 and 2024 in which they had reviewed quality programs and patient safety programs. During an interview with Chief Nursing Officer on 04/16/2025, it was revealed the agency did not ensure the hospice’s governing body assumed the legal authority and responsibility for the ongoing performance improvement and patient safety programs. This was evidenced by no documentation of annual hospice governing body meeting minutes and confirmed during the interview. The Chief Nursing Officer stated there “had not been Governing Body meetings for 2023 or 2024 in which they had reviewed the quality programs, patient safety programs or appointed persons to leadership positions.””

“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 1 of 11 (9%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific care instructions for the Hospice Aide. CLINICAL RECORD 8: Clinical record review revealed the initial nursing assessment dated 02/20/2025 included documentation that the patient was on “continuous oxygen at 3 liters per minute.” The hospice aide care plan dated 02/27/2025 documented frequency of aide visits twice a week and assigned the hospice aide the tasks for “vital signs (temperature, pulse, blood pressure, respirations)-every visit, bed linens-weekly, clothing assistance-every visit, bed bath-every visit, shampoo-every visit, skin care: apply lotion to skin after bed bath.” The hospice aide care plan did not include instructions for the aide related to the patient’s oxygen therapy while providing care to the patient. On 04/08/2025, a physician’s order for wound care documented a “Stage II [wound] to buttocks. Cleanse with normal saline. Pat dry. Apply Duoderm.” The aide care plan was not updated to include notification of the wound or specific instructions for the aide if the dressing became soiled, dislodged, or wet. During joint clinical record review and an interview on 04/15/2025, the Clinical Manager and Chief Nursing Officer acknowledged that the aide care plan did not include notification of oxygen therapy or wound treatment, and specific instructions to the aide had not been provided.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 11 (9%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 1/Home Visit 1: Clinical record review revealed the hospice aide care plan dated 02/27/2025 included documentation that aide frequency of visits was twice a week and assigned the aide the tasks of “vital signs (temperature, blood pressure, respirations and pulse), ambulatory with assistance, document last bowel movement, change clothes after each shower, oral care, shampoo, shave, shower, and skin care-apply lotion.” The tasks were to be completed every visit. The hospice aide documented on the aide visit dated 04/07/2025 patient “bedbound and bed bath for now.” During the home visit observation with the Hospice Aide (HA) (Personnel Record 7) on 04/16/2025, the Aide was observed to provide the patient with a bed bath instead of a shower. The hospice aide documented on the aide visit note dated 04/16/2025 “bed bath for now.” The aide did not provide services as ordered on the plan of care when the aide provided a bed bath instead of a shower as assigned on the aide care plan. During a joint clinical record review and interview on 04/16/2025, the Clinical Manager and the Chief Nursing Officer acknowledged that the aide had not been providing services ordered in the care plan and stated, “the nurse should have updated the care plan to a bed bath.””

“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 organization did not ensure hospice 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. During a review of the hospice volunteer hours and interview on 04/15/2025 with the Alternate Administrator, the Clinical Manager, and the Volunteer Coordinator. Documentation of the volunteer percentage for the past year from 04/15/2024 to 04/15/2025 showed the volunteer percentage was calculated to be 0.68%. The Alternate Administrator and the Clinical Manager described the organization’s difficulty with recruitment and explained they had recently hired a new Volunteer Coordinator, and the Volunteer Coordinator has onboarded two new active volunteers since November 2024. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided 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. An interview and document review was conducted with the Alternate Administrator, Clinical Manager, and Volunteer Coordinator on 04/15/2025, and the volunteer percentage for the past year (April 15th 2024 to April 15th, 2025) in either an administrative or patient care role, was calculated at 0.68%. They described difficulty with recruitment and had recently hired a new Volunteer Coordinator. The Volunteer Coordinator has onboarded two new active volunteers since November 2024.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator is an employee of the organization, informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities, and has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by personnel record review and interview. The organization did not ensure the Alternate Administrator was an employee of the hospice. Review of the Alternate Administrator’s personnel record revealed the Alternate Administrator was a contracted Registered Nurse with the contract start date of 07/08/2024. During interviews with the Chief Nursing Officer (CNO) on 04/14/2025 and 04/15/2025, the CNO confirmed that the RN was listed as the Alternate Administrator with the state beginning 07/08/2024 and was not a direct employee of the hospice. The organization hired and appointed Personnel Record 2 as the Alternate Administrator on 07/08/2024 through the end of the site visit on 04/16/2025. The employee, an RN, was a contractual employee. During the personnel record review with Human Resources Specialist and Clinical Manager on 04/15/2025, they confirmed this employee had always been a contractual employee.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of the 9 (22%) personnel records reviewed, the agency did not ensure the hospice assessed the skills and competencies of individuals providing care, including volunteers providing services. Agency policy 9747 Hospice Staff Competency Program, effective 02/21/2025, required in part, “1. Patient care staff will have competency assessed at defined intervals. For each new employee (including contract employees) during orientation. At least every two (2) years for all patient care staff. 2. Hospice has established competency criteria for each job category.” Personnel Record 4: Registered Nurse with direct patient contact, date of hire 10/11/2022. There was no documented evidence in the personnel record of skills and competencies being assessed upon hire or in 2024. Personnel Record 8: Volunteer with direct patient contact, date of hire 08/19/2024. The personnel record included documentation that skill and competency assessments were completed on 03/38/2025. However, there was no documented evidence that skill and competency assessment was completed at the time of hire. During joint personnel record review and interview on 04/15/2025, the Clinical Manager and the Human Resources Specialist confirmed competencies were not documented for Personnel Record 4 and 8. The Human Resource Specialist described a “new system they were implementing that would enable them to capture things more appropriately.””