Aspirus at Home

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review, interview and observation. In 2 of 2 (100%) Inpatient units (IPU) that were surveyed, the agency did not ensure that hot water was adequately monitored and tested for patient safety. During a walk-through of both inpatient units with maintenance and the nursing supervisor it was found that the facility was not doing any routine water temperature testing for patient water. IPU-1: The water temperature was tested in a patient room and measured 122.8 degrees Fahrenheit. In an interview with maintenance on 02/18/2025 in IPU-1, he stated that they have never kept records of testing water temperatures. He stated they do routine checks on the water system, there was no documented evidence of this. IPU-2: The water temperature tested in a patient room measured 140 degrees Fahrenheit. An interview was conducted on 02/29/2025 with the maintenance staff, and he stated that the water system was connected to an electronic system that could be monitored by an app on their phones. The app was supposed to alarm if the temperature went above 120. There was no documented evidence that the app was ever tested or that it was working correctly. In an interview with the clinical supervisor she agreed that there was no documented evidence of water testing and no documented evidence that the water monitoring system was working appropriately. (No associated K Tag) During a walk-through of both inpatient units with maintenance and the nursing supervisor it was found that the facility was not doing any routine water temperature testing for patient water. In IPU#1 the water temperature was tested in a patient room and measured 122.8 degrees Fahrenheit. In IPU #2 the water temperature tested in a patient room measured 140 degrees Fahrenheit. In an interview with maintenance on 02/18/2025 in IPU#1 he stated that they have never kept records of testing water temperatures. He stated they do routine checks on the water system, there was no documented evidence of this. In IPU#2 an interview was conducted on 02/29/2025 with the maintenance staff, and he stated that the water system is connected to an electronic system that can be monitored by an app on their phones. The app is supposed to alarm if the temperature goes above 120. There was no documented evidence that the app is ever tested or that it is working correctly. In an interview with the clinical supervisor she agreed that there was no documented evidence of water testing and no documented evidence that the water monitoring system is working appropriately.”

“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; other alternative treatments that could affect drug therapy. The medication review process includes the identification of 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, document review and interview. In 1 of 13 (8%) clinical records reviewed it was revealed that the agency did not ensure that all current medications were included in the patient’s drug profile. Document 1: Agency Policy titled, “Hospice Initial and Comprehensive Assessment” dated 05/2024 read in part, “The comprehensive assessment must take into consideration the following factors: Drug Profile. A review of the patient’s prescription and over-the-counter drugs, herbals and other alternative treatments that could affect drug therapy.”. Clinical Record 6: The election of the hospice benefit was dated 09/03/2024. The record revealed a physician’s order dated 09/03/2024 that read in part “Oxygen 2-4 liters via nasal cannula as needed for dyspnea.”. The medication profile dated 09/03/2024 did not include oxygen. In an interview on 09/11/2024, the Administrator reviewed the record, confirmed the finding and stated “Oxygen is not on the medication profile for this patient.””

“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 3 of 7 (43%) clinical records reviewed of patients with aide services provided it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 2: The record revealed a physician’s order dated 08/06/2024 that read in part “Place 16Fr Foley catheter with 10ml balloon.”. The aide care plan dated 08/06/2024 lacked instructions for catheter care. Clinical Record 9: The record revealed a physician’s order dated 06/29/2024 that read in part “Oxygen 2 liters via nasal cannula continuously.”. The aide care plan dated 06/29/2024 lacked instructions related to oxygen. Clinical Record 11: The record revealed a physician’s order dated 07/16/2024 that read in part “Oxygen 1 liter via nasal cannula continuously.”. The aide care plan dated 07/16/2024 lacked instructions related to oxygen. In an interview on 09/11/2024, the Administrator reviewed the records, confirmed the findings and stated “There are no instructions for foley catheter care or oxygen on these aide care plans but there should have been.””