Every finding on record at Assisted Home Hospice

Based on interview and record review, the hospice agency failed to ensure a home medication list, and instructions were provided for two of 19 sampled patients (Patients 14 and 13).This failure had the potential to result in the patients not receiving the correct medication, dose or frequency affecting quality of life. --- During a home visit for Patient 14 with a licensed nurse on 4/2/25 at 11:49 am, Patient 14’s home hospice binder was reviewed. The home medication list or medication instructions was not in the home binder. The patient’s caregiver with the power of attorney (POA) stated they don’t have a copy of Patient 14’s medication list.During an interview with the licensed nurse (LN2) on 4/2/25 at 12:19, LN2 stated she was not aware the POA did not have the home medication list.During a home visit for Patient 13 with the licensed nurse (LN1) on 4/2/25 at 3:15 pm, the home hospice binder was reviewed. The home medication list/instruction was not in the home hospice binder. The daughter of Patient 13 stated she does not have the home medication list/instructions.During an interview with the LN1 on 4/2/25 at 3:47, LN1 acknowledged home medication list/instruction was unavailable at the patient’s home.During an interview with the executive director (ED) on 4/3/25 at 11:47 am, the ED acknowledged the caregiver/POA should have a copy of the home medication list or instruction.The facility policy and procedure titled “Medication Management” dated 3/2019 indicated “ The patient or family shall be provided instructions regarding specific medication knowledge and skills as part of the patient’s plan of care and skilled nursing visit and described in Medication Education policy."

Based on interview and record review, the hospice agency failed to ensure social work home visits were followed as written in the plan of care for two of 19 sampled patients (Patients 6 and 11)This failure had the potential to result in the patient and family's social and emotional needs not being met. --- During a review of Patient 6’s health record on 4/3/25 at 11:02 am, plan of care (POC) indicated social work visit order of 1 visit weekly and 1 as needed every 7 days for the certification period 1/8/25 to 3/8/25. Review of the visit calendar indicated on week of 1/19/25to 1/25/25, 2/2/25 to 2/8/25, and 3/2/25 to 3/8/25 the social worker did not visit the patient. No missed visit documentation in the health record were located.During a review of Patient 11’s health record on 4/3/25 at 4:05 pm, plan of care (POC) indicated social work visit order of 2 visits monthly with 1 as need for every 30 days for the certification period of 2/6/25 to 4/6/25. Review of the visit calendar indicated the social worker had only visited the patient once a month instead of 2. No documentations of the missed visits were in the health record.During an interview with the director of patient care services (DPCS) on 4/4/25 at 11:21 am, the DPCS acknowledged the social work missed home visits for Patient 6 and 11.The facility policy and procedure titled “Hospice Interdisciplinary POC” dated 4/2022 indicates “A written plan of care must be established and maintained for each individual admitted to the Hospice, and the care provided to the individual must be in accordance with the plan”.

Based on interview and record review, the hospice agency failed to complete registered nurse (RN) supervisory visits every 14 days for five of 15 sampled patients (Patients 1, 2, 8, 10, 15) receiving hospice aide (HA) services.This failure had the potential to result in inadequate or inappropriate healthcare practices by hospice aides due to lack of supervision resulting in less than desirable care delivery. --- During a review of Patient 15’s “Face Sheet (FS),” dated 1/12/25, the FS indicated in part, Patient 15 is a 100-year-old female admitted for routine hospice care on 1/12/25 with a primary admitting diagnosis of Alzheimer’s Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).During a review of Patient 15’s “Plan of Care (POC),” for recertification period 1/12/25 – 4/11/25, the POC indicated the order, “Hospice Aide (HA) two (2) visit(s) weekly.”During a concurrent interview and record review on 4/4/25 at 11:43 a.m., with DPCS, Patient 15’s “Electronic Medical Record (EMR)” was reviewed.  The “Clinical Chart Search (CCS – a file-searching tool to find provider-specific charting and/or visit documentation)” section of the EMR for “HA Visit,” dated 8/1/24 – 4/3/25, indicated HA visits for Patient 15 started on 1/4/25.  When reviewing Patient 15’s “CCS for Supervisory Visit (SV),” dated 8/1/24 – 4/3/25, the record failed to indicate SVs were done in January 2025.  DPCS verbalized that SVs will be conducted by an RN at least 14 days after the start of HA services and every 14 days thereafter until HA visits are discontinued.  DCPS verbalized further and acknowledged that SVs should have been done for Patient 15 in January 2025.During review of the facility’s policy and procedures (P&P) titled, “Hospice Aide Supervision,” dated 3/24, the P&P indicated, “When Hospice Aide services are being provided, The RN (Registered Nurse) Case Manager or designated RN shall make an on-site visit to the patient at least every 14 days to assess whether the aide is following the patient’s plan of care and is competently completing tasks assigned by the RN…”  During a review of Patient 1's "Face Sheet (FS)," dated 10/09/24, the "FS" indicated, "Patient 1 is a 75-year-old female admitted to hospice on 10/09/24 for breast cancer."During a review of Patient 1’s “IDG assignments (IDG),” dated 02/07/25, the “IDG” indicated, “Hospice Aide: 1 visit weeklyDuring a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the Director of Patient Care Services (DPCS), “The Wellsky Hospice Electronic Clinical Charts Review (ECC),” dated 01/01/25 to 04/03/25 was reviewed for Patient 1. The “ECC” indicated, only one visit done in January on 01/27/25. The DPCS agreed, there were missing supervisory visits for January  for Patient 1.  During a review of Patient 2's "FS," dated 12/26/2024, the "FS" indicated, "Patient 2 is a 68-year-old female admitted to hospice on 12/26/24 for Parkinson’s disease (disorder of the central nervous system that affects movement)."During a review of Patient 2’s “Plan of Care (POC),” dated 2/18/25, the “POC” indicated, “Hospice Aide: 3 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 2. The “ECC” indicated, only one visit done March on 03/11/25. The DPCS agreed, there were missing supervisory visits for March for Patient 2.  During a review of Patient 8's "FS," dated 08/09/24, the "FS" indicated,  "Patient 8 is an 80-year-old male admitted to hospice on 08/09/24 for Parkinson’s disease."During a review of Patient 8’s “POC,” dated 3/21/25, the “POC” indicated, “Hospice Aide: 2 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 8. The “ECC” indicated, only one visit done March on 03/14/25. The DPCS agreed, there were missing supervisory visits for March for Patient 8.  During a review of Patient 10's "FS," dated 06/21/2024, the "FS" indicated, "Patient 10 is a 91-year-old female admitted to hospice on 06/21/24 for Chronic Obstructive Pulmonary disease (ongoing lung condition caused by damage to the lungs)."During a review of Patient 10’s “POC,” dated 2/5/25,the “POC” indicated, “Hospice Aide: 2 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 10. The “ECC” indicated, only one visit done in February  on 2/4/25 and one in March on 03/14/25. The DPCS agreed, there were missing supervisory visits for February and March for Patient 10. During review of the facility’s policy and procedure titled, “Hospice Aide Supervision,” dated 3/24, indicated, “When Hospice Aide services are being provided, The RN (Registered Nurse) Case Manager or designated RN shall make an on site visit to the patient at least every 14 days to assess whether the aide is following the patient’s plan of care and is competently completing tasks assigned by the RN…”

Based on interview and record review, the hospice agency (agency) failed to ensure the comprehensive assessment included a review of the patient's medication profile for one of 13 sampled patients (Patient 8) to identify potential drug duplication and side effects. This failure had the potential for all agency patients' medications to risk duplication of the medication, decrease the effectiveness of the medication or increase the potential for adverse consequences. Findings: During a concurrent interview and record review on 8/2/22, at 3:45 p.m., with executive director (Adm1), Patient 8's physician orders, dated 7/28/22, were reviewed. The physician orders indicated, A."MSIR (morphine sulfate oral immediate release) 15 milligram tab-give 1/2 tab (7.5 mg.) PO (by mouth) every one hour PRN (as needed) pain, SOB (shortness of breath) respiration over 28 per minute. B."MSIR (morphine sulfate oral immediate release) 5 milligram tab-give 1/2 tab PO/SL (by mouth-sub lingual) every one hour PRN pain, SOB (shortness of breath) respiration over 28 per minute. Adm 1 acknowledged that orders for same drug with different doses for same PRN reasons without directed variables, was not appropriate orders for nurses to determine when to administer what dose and route. During a concurrent interview and physician orders review on 8/22/22, at 4:20 p.m., with a clinical supervisor (Adm2), Adm2 acknowledged the current pharmacy mobile app utilized by nurses was unable to indicate side effects or duplication of medications.

Based on record review and interview, the hospice agency (agency) failed to ensure the services on the plan of care (POC) were followed, when hospice aide visits were not completed as ordered for one of 13 sampled patients (Patient 10). This failure had the potential to affect the quality of care provided to all patients serviced by the agency. Findings: During a concurrent interview and record review on 8/03/22, at 2 p.m., with clinical supervisor (Adm2), Patient's 10 interdisciplinary plan of care, dated 7/5/22, was reviewed. The POC indicated, "Hospice Aide frequency 5 times a week." Further record review revealed, hospice aide visit notes dated, "6/10/22-9/7/22, frequency 3 times a week." Review of hospice aide notes for the week of 7/5/22 indicated, only 3 hospice aide visits for the entire week, and throughout the month of July 2022. Adm2 acknowledged the hospice aide visit frequency was not adjusted per the interdisciplinary group's POC. Adm2 stated, "In SNF's (skilled nursing facilities), we are working at a better way to reflect the duties, but yes there were no visits at that frequency." During a review of the hospice agency policy titled, "Hospice Interdisciplinary Plan of Care,"dated 4/22, the hospice agency policy indicated in part, "A registered nurse coordinates the implementation of the plan of care for each patient and is responsible to ensure...Ongoing evaluation and assessment of the provision of hospice care for the patient and family..."

Based on record review and interview, the hospice agency (agency) failed to ensure that they included all the accurate drugs and dosages necessary to meet the needs of two of 13 sampled patients (Patient 8 and 11), when: 1. For Patient 8, the agency failed to ensure the orders for Haldol (a antipsychotic medication used to treat mental and mood disorders) were discontinued per physicians orders. 2. For patient 8, the agency failed to ensure the orders for Morphine (a narcotic used to treat moderate to severe pain) mediation had parameters for use for pain control. 3. For Patient 11, the agency failed to administer Tramadol (medication used to treat moderate to severe pain) according to physician's orders. These failures placed the patients at risk of not receiving or being administered all medications as prescribed by their physician(s); posing a risk for inaccurate medication administration, adverse medication side effects, duplicate drug therapy, and ineffective drug therapy. Findings: 1. During an interview with the executive director and (Adm1) and concurrent medical record review for Patient 8, on 8/2/22, stating at 3:45 p.m., Patient 8's record revealed Pt 8's medical doctor discontinued Patient 8's medication order for "Haldol 1 mg (milligram) PRN (as needed)" on 7/28/22. Further record review indicated, on 7/31/22, at 2:30 p.m., licensed nurse (LN1) administered Haldol 1 mg to Patient 8. Adm 1 acknowledged there was no physicians orders for the administered medication. Adm1 stated, "I am not sure why that happened." 2. During a concurrent interview and record review on 8/2/22, at 3:45 p.m., with executive director (Adm1), Patient 8's physician orders dated 7/28/22, was reviewed. Physician orders indicated, A."MSIR (morphine sulfate oral immediate release) 15 milligram tab-give 1/2 tab (7.5 mg.) PO (by mouth) every one hour PRN (as needed) pain, SOB (shortness of breath) respiration over 28 per minute. B."MSIR (morphine sulfate oral immediate release) 5 milligram tab-give 1/2 tab PO/SL (by mouth-sub lingual) every one hour PRN (as needed) pain, SOB (shortness of breath) respiration over 28 per minute. Adm 1 acknowledged that orders for same drug with different doses for same PRN reasons without directed variables, was not appropriate orders for nurses to determine when to administer what dose and route. Adm 1 acknowledged that orders for same drug with different doses for same PRN reasons without directed variables, was not appropriate orders for nurses to determine when to administer what dose and route. 3. During an interview with clinical supervisor (Adm 2) and concurrent Patient 11 medical record review on 8/3/22, starting at 4:45 p.m. a physician orders dated 4/30/22, indicated Patient 8 was ordered to receive "Tramadol 50 mg, 2 pills every night." Further record review revealed that on 7/26/22, at 8:30 a.m., licensed nurse (LN2) administered Tramadol, LN2's note indicated, "Routine nursing visit. Pt showing increased pain to stomach-tender to touch, gas pill and tramadol administered after 30 minutes pt calm. Requested to repeat in 6 hours..." Adm 2 acknowledged there was no PRN (when ever necessary) physician order for Tramadol and that the only order for Tramadol medication was for routine dose at evening. Adm2 stated, "Medication error, I will be speaking with my nurse about this." During a review of agency policy and procedure titled, "Medication Management", dated 3/19, the agency policy and procedure indicated in part..."The medication to be administered is identified as the correct medication and dosage...."

Based on interview and record review, the hospice agency (agency) failed to ensure the patient or patient's representative participated and agreed to the written plan of care ( POC) for one of 13 sampled patient (Patient 8). This agency failure has a potential to make care decisions without allowing the patient/patient's representative, make appropriate informed decisions regarding care needs and agree to the written POC for these patients. Findings: During a concurrent interview and record review on 8/2/22 at 3:45 pm., with the clinical supervisor (Adm2), Patient's 8 interdisciplinary group's (IDG) documentations, dated 7/21/22 were reviewed. The IDG lacked documentation of Patient 8 or Patient 8's representatives level of involvement and agreement into Patient 8's POC. Adm2 acknowledged lack of documentation and stated, "No, I don't see any [documentation] usually I do these, but I was on vacation and another staff who does not usually do initial assessments did this, and that's why it is probably missing." During a review of the agency policy and procedure titled, "Patient Care Assessment," dated 11/16, pg.2 of 3, indicated in part..."The assessment shall be integrated into the interdisciplinary plan of care: an analysis of this data shall facilitate the prioritization of patient's and family problems and needs for care, services and education, and the appropriateness of the level of care provided by the family to safely meet the patient's needs."

Based on observation, interview and record review the hospice agency (agency) failed to ensure one hospice aide (HA 1), was knowledgeable and trained appropriately for services she was allowed to provide for one sampled patient (Patient 1), when she was observed mixing thickener into a glass of juice. This failure had the potential to cause further swallowing difficulties for Patient 1 including choking due to improperly thickened liquids. Findings: During a home visit conducted on 8/2/22 between 9 AM and 11:45 PM, Resident 2's Assisted Living Facility, Resident 2 was noted to have increased pain and additional oral pain medication (morphine sulfate) was administered by the agencies skilled nurse. Resident 2 was sleepy and was not going to be able to be placed up in her wheelchair for activities and lunch in the dining room area. There were no liquids for hydration noted anywhere in Patient 1's room. Patient 1 had physician orders for nectar thick liquids due to her diagnosis of advancing dementia and dysphagia (swallowing difficulties). HA 1 and the SN were asked about how they planned on providing hydration for Patient 1. HA 1 was told to go ask the facility for some nectar thick water or juice to have at the bedside. At 11:15 AM, in the dementia unit small kitchen and dining room area, HA 1 was observed adding canned thickening powder to a glass of juice. HA 1 was stopped and asked if she had any training on making thickened liquids for dysphagia diets? HA 1 stated, "No, I haven't." The SN also indicated she thought the HA's had training on mixing thickener into fluids for patient's with dysphagia, but she was wrong. A review of HA 1's employee file reveled a job duty description which indicated in part, " ESSENTIAL DUTIES AND RESPONSIBILITIES...Assist patient with ...nutritional support / feeding...according to the patient's needs and nursing orders." No where in HA 1's file was there any evidence she had been trained on how to appropriately mix thickened liquids. In an interview with the Assisted Living Facility's Healthcare Services Director (AFHSD) on 8/2/22 at 11:57 PM, the AFHSD stated, "All thickened liquids are to be mixed in the main kitchen by trained dietary staff only."

Based on interview and record review the facility failed to ensure the clinical record of one of 13 patients (Patient 3) contained correct clinical information that was available to the patient's attending physician and hospice staff when Patient 3's DNR status documented on the patient's POLST did not match the DNR status documented on the patient's Psychosocial Assessment. This failure has the potential for Patient 3's wishes not to be honored during an emergency. Findings: During a review of Patient 3's "Emergency Medical Services Prehospital Do Not Resuscitate (DNR) Form,"dated 3/16/22, the form indicated, "I understand DNR means if my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart functioning will be instituted...I hearby agree to the "Do Not Resuscitate" (DNR) order." The form was signed by Patient 3's legally recognized health care decisionmaker. During a review of Patient 3's "Physician Orders for Life-Sustaining Treatment (POLST)," dated 3/16/22, the POLST indicated, "Do Not Attempt Resuscitation/DNR (Allow Natural Death). The POLST was signed by Patient 3's primary care physician. During a review of Patient 3's "Psychosocial Assessment," dated 3/16/22, the assessment indicated, under F2000-F2200 Advance Directives, "Reviewed patient end-of-life preferences with responsible party. The confirmed their wishes for the following: CPR: (a checkmark was placed after CPR). Other life-sustaining treatments: (a checkmark was placed after other life-sustaining treatments). During a concurrent interview and record review on 8/4/22, at 11:35 a.m., with the clinical supervisor (Adm 2), Patient 3's DNR form, POLST, and Psychosocial Assessment were reviewed. Adm 2 stated, "It's unclear what the Social Services Worker(LCSW) meant by putting a checkmark".

Based on interview and record review, the hospice agency (agency) failed to ensure one of 13 patients' records (Patient 7) adhered to professional standards of practice and facility policy when Patient 7 had a wound that was not documented completely. This failure has the potential for Patient 7 to not receive the correct wound care treatment as it was unknown if the wound improved or declined. Findings: According to Royal College of Nursing (2012), "A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, color and shape, as well as the condition of surrounding skin, should all be documented. This vital information indicates the stage and progress of the wound and is vital to ensure that the next clinician caring for the patient selects an appropriate dressing." During a review of of the facility's policy and procedure (P&P) titled, "Management of Wounds and Pressure Ulcers," revised 12/16, the P&P indicated, "Wounds are to be measured at lease weekly noting width, length and depth, color, drainage and condition of surrounding skin. The wound skin surface dimensions is measured as length x width...All patients with wounds will be assessed for effectiveness of wound care treatment...Any new wounds identified during current treatment need additional orders and a change of condition written for the new wound even though the treatment parameters may be the same." During a review of Patient 7's "Patient Information," dated 12/15/21, the information indicated, Patient 7 was admitted on 7/28/21 with diagnoses including, Alzheimer's disease and cerebral infarction. Patient 7 was incontinent of bowel/bladder, required assistance with feeding, bathing, dressing, and transfers. During a review of Patient 7's "Hospice Nursing Assessment/Plan of Care & Physician Orders", dated 8/2/21, the assessment indicated, under, "Briefly describe course of patient's terminal illness, "...non healing wounds" and under Skin Integrity Impairment, "BLE (bilateral lower extremities) and bilat (bilateral) buttocks blisters. Under Goals and Interventions, Wound care procedure and supplies was checked and the area blank where the wound care and supplies were to be listed. During a review of Patient 7's "Hospice Nursing Visit Note," dated 6/3/22, the note indicated, under Altered Skin Integrity, open right hip, left hip blisters. Wound care: wound cleanser, TAO (treatment as ordered), border foam. There was no descriptions of the blisters. During a review of Patient 7's "Hospice Nursing Visit Note," dated 6/21/22, the note indicated, under Altered Skin Integrity, Stage 2 Right hip. Wound care: wound cleansed, pat dry, 3x abx (triple antibiotic), border foam. There was no description of the Stage 2 right hip wound. There was no evidence a change of condition had been completed for the Stage 2 wound. During a review of Patient 7's "Hospice Nursing Visit Note", dated 6/24/22 and 7/1/22, the notes indicated, under Altered Skin Integrity, Stage 2 Right hip. Wound care: border foam, TAO. There was no description of the Stage 2 right hip wound. During a review of Patient 7's "Hospice Nursing Visit Note", dated 7/5/22, the note indicated, under Altered Skin Integrity, Stage 1 Right hip. Wound care: wound cleanser, tao, border foam. There was no description of the Stage I right hip wound. During a review of Patient 7's "Hospice Nursing Visit Note", dated 7/29/22, the note indicated, under Altered Skin Integrity, Wound (type) excoriation right hip, blisters x2 left hip and left thigh. Wound care: calmoseptine, border foam. There were no descriptions of the blisters or the excoriated area. During a concurrent interview and record review on 8/4/22, at 9:45 a.m., with the nursing supervisor (Adm 2), Patient 7's Change of Condition reports and Nursing Visit Notes were reviewed. The Adm confirmed the wound care documentation was incomplete and a change of condition was not done.

Based on interview and record review, the hospice agency (agency) failed to provide a qualified social worker to provide medical social services for 10 out of 13 sampled patients (Patients 1- 9 and Patient 13). This agency failure had a potential to result in inefficient care and services being provided to the patients. Findings: During a concurrent employee record review and interview with Human Resource Director (HRD) on 8/2/22, starting at 11:30 a.m., social worker (SW1) employee file indicated, SW1 had been employed at agency since 2/28/20. Further record review indicated, SW1 only had a degree in psychology and had never been employed as a social worker prior to current position. HRD indicated, SW1 reported to the RN clinical supervisor. SW1 job description does not indicate social worker required supervision.