Every finding on record at Beloit Health System

Based on record review and interview hospice staff failed to keep patient free from mistreatment in 1 (Patient #1) of 1 patient record in a total sample of 11 patients reviewed. --- Findings Include:Agency policy titled, "Abuse, Neglect, Mistreatment, and Exploitation” dated 10/2022, revealed in part, “Definitions: Mistreatment: To treat someone or something roughly, wrongly, or badly…1. During orientation (and annually thereafter), all new employees receive instruction regarding: b. a review of the State's legal definitions of abuse, neglect, and exploitation and mandatory reporting requirements and processes. 2. During the admission process and throughout the course of care, hospice personnel assess the potential/likelihood of abuse, neglect, mistreatment, or exploitation in the patient’s environment. 3. Alleged violations of abuse, neglect, mistreatment and/or exploitation involving hospice employee or contractor are brought to the attention of the hospice administrator immediately. 4. The administrator or designee immediately investigates alleged violations involving persons providing services on behalf of the hospice and immediately takes action to prevent potential further violation during the investigation.” Record review of Patient #1's medical record revealed in part, a start of care date of 12/17/2024 with a Terminal Diagnosis of Senile degeneration of brain. Patient #1’s Physician Certification of Terminal Illness was dated 06/11/2025. Clinical note dated 07/14/2025 revealed Certified Nursing Assistant (CNA) C provided "partial cares done today, Administrator A called during cares and this CNA was dismissed from room by staff at ALF (Assisted Living Facility)." Clinical note dated 07/14/2025 revealed Registered Nurse (RN) D completed a visit on Patient #1 due to “Received message that patient has 3 new-onset skin tears to her right forearm…Skin Integrity: Patient has 3 new skin tears to her right forearm, measuring 3.5cm x 0.2cm x 0.1sm to her dorsal forearm, 2.3cm x 0.2cm x 0.1cm to lateral wrist, and 7cm x 0.2cm x 0.1cm to her dorsal hand. Wound cares provided. Orders written out and given to facility Wellness Director H. Visit frequency increased to 2x/week for wound cares." RN Supervisory visit was completed (aide not present) with documentation noted, “Change in service, new aide assigned.”Record review of CNA C’s personnel record indicated a date of hire of 02/02/2024. CNA C’s personnel record did not contain any evidence of any orientation or training regarding Patient Rights or Abuse, Neglect, and Mistreatment. A performance evaluation dated 03/07/2025 did not reveal any concerns with care or performance.Also in CNA C's personnel file was a document (dated 07/18/2025) detailing the 07/14/2025 incident revealing in part, “I went to pull the covers and she [Patient #1] grabbed them and became verbally abusive telling me to go away, she hates me and she wished I would die. I slowly and calmly started to take off her sleeping gown, it has a zipper in the front. I managed to get it off one are and was going to the other side to roll her and get the gown and she started hitting me and yelling. She was grabbing the gown and hitting my hands at the same time but I got the gown away from her. I was continuing with my cares when I noticed blood on my hands and that is when I discovered the large skin care on her right hand, at this point I am not sure what caused it, but I think it might have been the zipper on the gown. I applied pressure and put her call light on, I attempted to call one of my coworkers for help but she was already gone. I waited and when no one came in the room I went out into the hallway and asked the male CNA for a nurse stating I was needing help pretty quickly. I waited longer and then [Wellness Director H] came into the room and I was pretty frazzled at that point, the patient was yelling saying she hated me and to get me out of there. [Wellness Director H] told me it was all in my approach to the patient (she wasn’t there to see my interactions with her) and then she dismissed me from the room stating she would take care of all of it herself…” During an interview with Administrator A on 07/21/2025 at 1:25 PM Administrator A stated that she was made aware of a situation involving Patient #1 and CNA C when she received a phone call from CNA C on 07/14/2025. Administrator A stated CNA C reported she was at the assisted living facility and had been providing aide cares to Patient #1 when #1 became combative and CNA C requested assistance. CNA C stated that Wellness Director H came into the room to assist and H instructed CNA C to leave and she would provide the necessary cares to Patient #1. Administrator A stated that she briefly spoke with Wellness Director H and H informed her that CNA C was clearly angry with Patient #1 and was handling #1 in a rough manner causing three skin tears on Patient #1 and she wanted CNA C to leave the facility immediately. Administrator A agreed and instructed CNA C to leave the facility and she was not to provide cares to any patient at the facility and her patients would be reassigned to someone else. During an interview with Wellness Director H on 07/22/2025 at 10:27 AM, Wellness Director H stated that on 07/14/2025, she was told CNA C needed help with Patient #1, so she went to Patient #1’s room to assist. Wellness Director H stated, “As soon as I entered [Patient #1’s] room I could tell [CNA C] was upset and very frustrated and said, 'I can’t do this alone. I need two people. She’s being very combative.' I then told her that maybe it was her approach. I have worked with [Patient #1] and I’m comfortable with her. Then [CNA C] went up to [Patient #1] and grabbed her right forearm with both of her hands gripped around it and said, 'She’s being very combative.' I went up to [Patient #1] and said good morning and asked her if there was anything I could do for her. [Patient #1] said, 'Good morning. Not too good I don’t know what I did to this woman to hurt me like this.' [Patient #1] then showed me her right arm and I saw three new skin tears. It was fresh blood and had just started to drip down. That’s when I asked [CNA C] what happened. [CNA C] said, 'I don’t know I was just getting her ready for the day.' I then told [CNA C] she needed to leave and I would finish the cares on [Patient #1]. She continued to wring out the washcloth as if she was going to continue to provide cares so I told her again she needed to leave. That’s when she called [Administrator A] and told her that one of the staff from here was in the room accusing her and yelling at her. [CNA C] asked for my name and that’s when I asked to speak with [Administrator A] on the phone. Then I told [Administrator A] what happened and that I told [CNA C] to leave. Administrator A agreed and said they would meet up later and discuss later. I finished cares on [Patient #1] and she was very upset and kept repeating, ‘Please don’t let her come back.' I contacted [POA/Family Member I], my director, and her provider Inclusa, and explained the situation to all of them. I have not had any more communication with [CNA C]. I did speak with [RN D] that same morning when he came in and assessed [Patient #1] and cleaned the wounds and applied dressings.” When asked if she was aware of any prior issues or concerns with CNA C, Wellness Director H stated that CNA C had previously requested [Patient #1] be medicated with Lorazepam prior to morning cares. Director H stated that her request was discussed and denied because they felt like it was not needed, and it was all in the approach with Patient #1.

Based on record review and interview, agency failed to ensure all staff completed patient rights, abuse, neglect, and mistreatment training in 3 (Certified Nursing Assistant (CNA) C, Registered Nurse (RN) D, and Hospice Aide G) in a total of 5 personnel files reviewed. --- Findings Include:Review of agency policy titled, “Staff Education and Training”, dated 11/2024, revealed in part, “New staff members will complete an orientation training process that will identify their level of competency and establish an action plan to assure competency in their key job functions. Educational topics to be included in the initial orientation are: Patient Rights and ethics, Abuse and Neglect…”Record review of CNA C’s personnel record indicated a date of hire of 02/02/2024. CNA C’s personnel record did not contain any evidence of any orientation or training regarding Patient Rights or Abuse, Neglect, and Mistreatment.Review of personnel record for RN D revealed in part, a date of hire of 04/15/2024. There was no evidence of any patient rights, abuse, neglect, and mistreatment completed trainings in RN D’s personnel file. Review of Hospice Aide G’s personnel record revealed in part, a date of hire of 02/21/2024. There was no evidence of any patient rights, abuse, neglect, and mistreatment completed trainings in Hospice Aide G’s personnel file.During an interview with Administrator A on 07/22/2025 at 9:38 AM, when asked if CNA C, RN D, and Hospice Aide G had completed Patient Rights, Abuse, Neglect, and Mistreatment as part of orientation or other training, Administrator A stated, “No. It looks like there was some miscommunication between our education department and Human Resources (HR) and those specific trainings were never assigned to a few new staff..."

Observed in Emergency Management Session. The hospice organization’s emergency operations plan did not identify the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. This was discussed with the Director.

Observed in HR File Review. In 1 of 9 HR files reviewed, the organization had not provided initial education and training in emergency management to all new and existing staff, individuals providing services under arrangement. There was no documentation of initial training about the hospice emergency management plan in the file for HR6, a contracted individual. This was confirmed with the Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not completed the comprehensive assessment within 5 calendar days of the election of hospice care. In the chart for RRNHV#5, the hospice surveyor noted that the patient was admitted eleven days prior to the date of the beginning of the survey, yet the spiritual needs of the patient had not yet been assessed. This was discussed with the Director.

Observed in Record Review. In 2 of 19 patient records reviewed, the hospice had not documented a complete, comprehensive assessment upon admission. In the charts for RRHV#4 and RRNHV#9 there was no documented bereavement risk assessment. This was discussed with the Director.

Observed in Record Review. In 2 of 19 patient records reviewed, the assessment had not been updated with progress toward goals. For example, in the chart for RRHV#1, a social work goal on the plan of care identified upon admission was the patient/caregiver would identify final arrangements with a date approximately three months into the future. There was no information in the interdisciplinary group documentation which address any progress toward this goal. In the chart for RRHV#2, there was no documented progress toward the goal of reduction in the patient's anxiety for more than three IDG meetings.

Observed in Record Review. In 5 of 19 patient records reviewed, the plan of care did not include patient specific goals. In the chart for RRHV#1, the patient had oxygen ordered upon admission as part of the comfort medications. There was no goal on the plan of care for oxygen safety. In the chart for RRHV#2, the patient was admitted with a skin tear. There was no goal on the plan of care related to the wound. The Spiritual Care goal was a statement of what the Spiritual Care Counselor was going to provide to the patient rather than a goal and did not include a measurable time frame. In the charts for RRHV#3 and RRHV#4, the patients had oxygen upon admission. There was never a goal related to safe oxygen use on the hospice plans of care. In the chart for RRNHV#5, there was no time frame for the goal of ___ and family will verbalize understanding of use of Norco and Morphine in the home. This was confirmed with the nursing supervisor and Administrator.

Observed in Record Review. In 4 of 19 patient records reviewed, the hospice plan of care did not include all services needed to meet the patient's needs. In the charts for RRHV#3 and RRHV#4, the patients were admitted on oxygen, yet the plans of care did not include any teaching interventions related to safe use of oxygen. In the chart for RRHV#2, the patient was admitted with a skin tear. The wound care order was missing the frequency that the wound care was to be performed. In the chart for RRNHV#5, the RN assessed the patient was using oxygen continuously at 2lpm at the time of admission. There was no order for oxygen on the hospice plan of care. This was discussed with the DON

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not provided the patient with care according to the hospice plan of care. In the chart for RRHV#2, the volunteer was ordered to be provided weekly. The volunteer visits were provided every other week for more than two months as confirmed with the Director of Nursing.

Observed in HR File Review. In 1 of 9 HR files reviewed, the organization had not documented orientation to all staff. In the file for HR6, there was no documentation that orientation occurred about hospice philosophy for the contracted Medical Director. This was confirmed with the Director.

Observed in HR File Review. In 1 of 9 HR files reviewed, the organization had not provided education consistent with law and regulation. In the file for HR8, there was no documentation of annual infection control/blood borne pathogen education as required by OSHA. This was confirmed with the Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record was incomplete. In the chart for RRNHV#11, the documentation of the interdisciplinary group revision of the plan of care had not been documented in the patients medical record for two meetings at the time of the survey. This was discussed with the Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#13, there was an IDG note from the month prior to the survey which was labeled with a different patient's name and plan of care update. This was discussed with the Director.

Observed in Record Review. In 1 of 5 patient records reviewed, for the patient in a skilled nursing facility the plan of care did not specify which provider is responsible for performing the care. In the chart for RRHV#2, the patient was admitted with a skin tear which the nurse documented in the assessment that the facility was providing wound care for. The plan of care did not state which provider was to perform the wound care. This was discussed with the Director of Nursing.

Observed in HR File Review. In 3 of 9 HR files reviewed, the organization had not obtained criminal background checks within three months of employment for the states that the individual has lived in or worked in during the past three years. In the files for HR1, HR5 and HR9 there was no criminal background check for the state of Illinois; the individuals have professional licensure in IL and/or see patients for the organization in Illinois. This was discussed with the Director.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization did not inform the patient of their financial responsibility prior to the initiation of care. In all clinical records reviewed, the hospice surveyor noted the patient's admission consent form or election of benefit did not specify an approximate dollar amount the patient would be responsible to pay. This was confirmed with the clinical team lead.

Observed in Record Review. In 6 of 13 patient records reviewed, the hospice did not conduct and document in writing a patient-specific comprehensive assessment. In HSP HV #2, the hospice surveyor noted the nurse did not perform a skin assessment the second week of service although the patient stated she needed a donut for her buttocks. This was confirmed with the clinical team lead. In HSP RR #1, the hospice surveyor noted the skilled nurse did not reassess the patient's anxiety level at the comprehensive assessment visit performed after admission although this was an identified issue for the patient. This was confirmed with the clinical team lead. In HSP RR #2, the hospice surveyor noted the skilled nurse did not obtain wound measurements on the admission visit or at the visits on the second, third and fourth weeks of service. This was confirmed with the clinical team lead. In HSP RR #3, the hospice surveyor noted the skilled nurse did not obtain wound measurements on the admission visit for the 6 wounds identified. This was confirmed with the clinical team lead. In HSP RR #6, the hospice surveyor noted the patient was identified as having a wound on admission; however, there was no documentation of a wound assessment. This was confirmed with the clinical team lead. In HSP RR #7, the hospice surveyor noted the patient had a g-tube on admission; however, there was no assessment of the g-tube site. This was confirmed with the clinical team lead.

Observed in Record Review. In 1 of 16 patient records reviewed, the comprehensive assessment did not assess the patient's spiritual needs. In HSP RR #7, the surveyor noted the hospice chaplain assessment did not include faith/spiritual concerns identified or if the patient identified with a formal religion. This was confirmed with the clinical team lead.

Observed in Record Review. In 2 of 13 patient records reviewed, the comprehensive assessment did not include imminence of death. In HSP RR #6 and HSP RR #7, the hospice surveyor noted the skilled nurse did not assess imminence of death on admission visit or the first comprehensive assessment after admission. This was confirmed with the clinical team lead.

Observed in Record Review. In 9 of 13 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HSP HV #3, the hospice surveyor noted the goals on the plan of care did not include time frames. In addition, the plan of care included the non-measurable goal: reduction in anxiety level - anxiety will be managed so Elmer can sleep and visit with family. This was confirmed with the hospice clinical manager. In HSP RR #1, the hospice surveyor noted the goals on the plan of care did not include time frames. In addition, the plan of care included the non-measurable goal: reduction in anxiety level - will be able to rest without anxiety. This was confirmed with the clinical team lead. In HSP RR #2 and HSP RR #9, the hospice surveyor noted the goals on the plan of care did not include time frames. This was confirmed with the clinical team lead. In HSP RR #3, the hospice surveyor noted the plan of care included the following non-measurable goals: patient will verbalize pain control so she may experience quality of life throughout 15 day IDG period. Create a comfortable, peaceful place to visit with patient, provide support visiting patient. This was confirmed with the clinical team lead. In HSP RR #4, the hospice surveyor noted the plan of care included the following non-measurable goals: dyspnea on exertion, BP and HR will be managed so she can continue to enjoy participating in activities with friends. Patient will verbalize limitations of disease process - Pt verbalizes understanding of her disease process, wants to be as active as possible, prefers to have her solitude, wants to keep hospice team at a distance. Reduction in skin impairment - daily dressing change to left shin. did not specify what provider was to perform wound care. In addition, the goals did not include time frames. This was confirmed with the clinical team lead. In HSP RR #5, the hospice surveyor noted the plan of care included the following non-measurable goals: patient will feel comfortable verbalizing her feelings so they can be addressed immediately through intervention prevening a full on anxiety attack. fluid retention will be monitored. This was confirmed with the clinical team lead. HSP RR #6, the hospice surveyor noted the plan of care included the following non-measurable goals: Cardiopulmonary symptoms managed so he may maintain optimal independence. Patient will verbalize pain control . Satisfactory respiratory rate, depth and ease may maintain optimal independence. Hospice will ensure comfort medications are provided. This was confirmed with the clinical team lead. In HSP RR #7, the hospice surveyor noted the plan of care included the following non-measurable goals: Optimal mobility within disease restrictions. This was confirmed with the clinical team lead.

Observed in Record Review. In 10 of 13 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HSP HV #2, the hospice surveyor noted the patient was identified as having pain and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical team lead. In HSP HV #3, the hospice surveyor noted the patient was identified as having pain, skin breakdown risk, edema and diarrhea; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical team lead. In HSP HV #1, the hospice surveyor noted the patient developed anxiety, constipation and difficulty swallowing; however, the plan of care was not updated to reflect these identified needs. In addition, the second month of the certification period, nurse documented patient transitioning; however, there was no update to the plan of care to address imminence of death. This was confirmed with the clinical team lead. In HSP RR #2, the hospice surveyor noted the patient was identified as having pain; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead. In HSP RR #3, the hospice surveyor noted the patient was identified as having pain, diarrhea and agitation on admission; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical team lead. In HSP RR #5, the hospice surveyor noted the patient was identified as having skin breakdown and risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical team lead. In HSP RR #6, the hospice surveyor noted the patient was identified as having pain and at risk for falls; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead. In HSP RR #7, the hospice surveyor noted the plan of care included a goal for seizures, optimal mobility and cognitive impairment; however, there were no interventions to reach these goals. This was confirmed with the clinical team lead. In HSP RR #8, the hospice surveyor noted the patient was identified as having seizures; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead. In HSP RR #9, the hospice surveyor noted the patient was identified as having agitation; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead. In HSP RR #10, the hospice surveyor noted the patient was identified as having fall risk; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead.

Observed in Record Review. In 2 of 13 patient records reviewed, the plan of care did not include a detailed statement of the score and frequency of services necessary to meet the specific patient and family needs. In HSP HV #1 and HSP HV #2, the hospice surveyor noted the plan of care visit frequency for skilled nursing was 2 week 1 only; therefore the plan of care did not include a visit frequency for skilled nursing past the first week of service. In addition, In HSP HV #2, the plan of care did not include a visit frequency for hospice aide services although the patient was receiving hospice aide services. This was confirmed with the clinical team lead.

Observed in Record Review. In 11 of 13 patient records reviewed, the plan of care did not include all drugs and medications necessary to meet the needs of the patient. In HSP HV #2, the hospice surveyor noted the plan of care indicated comfort kit medications which include morphine which was in the home at the time of the visit; however, the clinical record indicated the patient was allergic to morphine. In addition, the plan of care included PleurX dressing change as needed; however, did not specify the care to be provided or give an indication when this was to be performed. This was confirmed with the clinical team lead. In HPS HV #1, the hospice surveyor noted the patient had a foley catheter on admission; however, the plan of care did not specify size, frequency of change, and balloon size. In addition, there was a written order that indicated change foley per nursing assessment. May irrigate or change prn obstruction. In addition, the patient was on coumadin; however, the plan of care did not specify the frequency of PT/INR. Also, the patient developed a stage 1 pressure ulcer on buttocks; however, plan of care was not updated regarding care of this area. The organization did not obtain an order for PT/INR performed the second month of service. This was confirmed with the clinical team lead. In HSP RR #2, the hospice surveyor noted the plan of care did not specify a diet type or safety measures. In addition, the wound care orders indicated prn; however, did not specify the indication. This was confirmed with the clinical team lead. In HSP RR #3, the hospice surveyor noted the plan of care did not specify a diet type of safety measures. In addition, the patient was identified as having 6 wounds on admission; however, the plan of care did not include wound care interventions. This was confirmed with the clinical team lead. In HSP RR #5, the hospice surveyor noted the plan of care did not include safety measures or specify a diet type. In addition, the plan of care included an intervention to take weights prn as indicated by signs/symptoms; however, the plan did not specify the signs and symptoms that would indicate the weight to be obtained. This was confirmed with the clinical team lead. In HSP RR #4, the hospice surveyor noted the plan of care did not include safety measures. In addition, the plan of care included the medication order furosemide 10 mg 1/2 tablet daily; however, furosemide is not available in a 10 mg tablet. This was confirmed with the clinical team lead. In HSP RR #6, the hospice surveyor noted the patient was identified as having a wound on admission; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical team lead. In HSP RR #7, the hospice surveyor noted the plan of care did not specify the DME required, did not identify safety measures, and did not specify the diet type. In addition, the medication order on the plan of care indicated: Bisacodyl suppository indicated prn; however, it did not specify the frequency of administration (daily prn). Also, another medication order on the plan of care indicated Hydrocortisone 1% cream indicated as directed every 6 hours prn to affected areas; however, did not specify the indication or the affected area. This was confirmed with the clinical team lead. In HSP RR #8, the hospice surveyor noted the plan of care indicated insert foley catheter irrigate and change PRN; however, the patient already had a foley catheter, the order did not indicate size, balloon size, indication for change, and irrigation solution, volume and frequency. In addition, the patient was on insulin sliding scale before meals; however patient was on tube feeding; however, no interventions identified to address diabetes including blood sugar frequency. The plan of care did not include the diet type, the tube feeding type, volume, pump or gravity, free fluid. Also the plan of care did not specify safety measures such as aspiration precautions. This was confirmed with the clinical team lead. In HSP RR #9, the hospice surveyor noted the plan of care did not include DME, safety measures or diet type. In addition, the plan of care Indicated finger stick blood sugars; however, the patient was not diabetic. This was confirmed with the clinical team lead. In HSP RR #10, the hospice surveyor noted the patient had a foley catheter; however, the plan of care did not specify the size, balloon and frequency of change. This was confirmed with the clinical team lead.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice interdisciplinary group did not revise and document the individualized plan as frequently as every 15 calendar days. In HSP RR #1, the hospice surveyor noted the interdisciplinary group did not review and revise the plan of care as evidenced by there was no documentation of IDG meeting since start of care 18 days ago. This was confirmed with the clinical team lead. In HSP HV #1, the hospice surveyor noted in the third certification period the IDG meetings were 6 weeks apart. This was confirmed with clinical team lead. In HSP RR #7, the hospice surveyor noted there was no documented IDG meeting since the start of care 17 days ago. This was confirmed with the clinical team lead.

Observed in Record Review. In 7 of 13 patient records reviewed, the organization did not provide the patient with care, treatment or services according to the patient's individualized plan of care. In HSP HV #2, the hospice surveyor noted the plan of care indicated the nurse was to evaluate for respiratory complications; however, the nurse did not assess the patient's lung sounds on the third visit note after the patient received pleurx drainage. In addition, there was no assessment of chest pain as required by the plan of care. This was confirmed with the clinical team lead. In HSP HV #1, the hospice surveyor noted the plan of care hospice aide visit frequency was two times per week; however, the second week of service the hospice aide only provided one visit. In addition, the plan of care required pain to be reassessed at each visit; however, the nurse failed to reassess the patient's pain on the fourth week of service. This was confirmed with the clinical team lead. In HSP RR #4, the hospice surveyor noted the hospice aide visit frequency one time per week; however, the aide performed two visits per week since the start of care. This was confirmed with the clinical team lead. In HSP RR #5, the hospice surveyor noted the skilled nursing visit frequency on the plan of care indicated two times per week; however, the third week of service the nurse only visited the patient one time per week. In addition, the skilled nurse applied a foam dressing to the sacrum for skin prevention; however, this intervention was not on the plan of care. This was confirmed with the clinical team lead. In HSP RR #6, the hospice surveyor noted the aide visit frequency on the plan of care was one time per week; however, the patient was not seen the third week of service. This was confirmed with the clinical team lead. In HSP RR #7, the hospice surveyor noted the skilled nurse did not reassess for seizures at two routine visits as required by the plan of care. This was confirmed with the clinical team lead.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the hospice did not implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. In HSP HV #2, the hospice surveyor noted the skilled nurse did not allow for the required 2 minute wet time when cleaning blood pressure cuff, thermometer, pulse oximeter and stethoscope as specified by the disinfectant manufacturer's IFUs. This was confirmed with the hospice clinical manager. Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HSP HV #2, the hospice surveyor noted the nurse performed hand hygiene, donned the gloves from the pleurx kit and then removed the patient's dressing, performed draining and then performed site care with the same gloved hands; however, the policy Nursing Care of the Pleurx Drainage System required the nurse to don gloves remove the dressing, then doff gloves, perform hand hygiene and don the gloves from the kit. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 9 of 11 patient records reviewed where the patient received hospice aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HSP HV #1, the hospice surveyor noted the patient had a foley catheter; however, the aide plan of care did not include foley catheter care. In addition, the aide plan of care did not include bleeding precautions or fall precautions. This was confirmed with the clinical team lead. In HSP HV #2, the hospice surveyor noted the patient reported she required and had a shower bench; however, the aide plan of care did not include this. In addition, the aide plan of care did not include fall precautions. This was confirmed with clinical team lead. In HSP HV #3 and HSP RR #6, the hospice surveyor noted the aide plan of care did not include fall precautions and oxygen safety precautions. This was confirmed with the clinical team lead. In HSP RR #1, HSP RR #2, HSP RR #4, HSP RR #5 and HSP RR #7, the hospice surveyor noted the aide plan of care did not include fall precautions. This was confirmed with the clinical team lead. In HSP RR #8, the hospice surveyor noted the aide plan of care did not include aspiration precautions or instructions related to the g-tube site. This was confirmed with the clinical team lead.

Observed in Record Review. In 3 of 11 patient records reviewed where the patient received hospice aide services, the hospice aide did not provide services included in the plan of care. In HSP RR #3, the hospice surveyor noted the hospice aide documented on two visits notes hair care NA; however, this task was assigned by the RN to be performed and there was no documentation the RN was notified it was not performed. This was confirmed with the clinical team lead. In HSP RR #4, the hospice surveyor noted the patient refused the shower the second and third week of service; however, there was no documentation the nurse was notified. This was confirmed with the clinical team lead. In HSP RR #6, the hospice surveyor noted the hospice aide documented sponge bath NA; however, no documentation that the nurse was notified the sponge bath was not performed. This was confirmed with the clinical team lead.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, 418.104, 418.54 and 418.56.

Observed in HR File Review. In 2 of 7 HR files reviewed, staff competence was not assessed and documented annually as required by organization policy. In HSP HR #7, the hospice surveyor noted the medical director did not have competence assessed in the past three years as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the HR director. In HSP HR #8, the hospice surveyor noted the volunteer returned to service after four years; however, the organization did not assess the volunteer's compliance upon return. This was confirmed with the interim volunteer coordinator.

Observed in Record Review. In 2 of 13 patient records reviewed, the clinical record did not contain correct clinical information. In HSP RR #1, the hospice surveyor noted the aide documented that the sponge bath was performed and then in narrative indicated sponge bath was not performed as facility staff had already completed. This was confirmed with the clinical team lead. In HSP RR #3, the hospice surveyor noted the skilled nurse inaccurately documented the patient had an IV site on admission. In addition, the nurse documented the wrong date, one day before the visit occurred, on the clinical note. This was confirmed with the clinical team lead.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the patient record did not contain an accurate medication list. In HSP HV #2, the hospice surveyor noted the medication profile had duplicate medications of Tylenol and Acetominophen 500 mg po. Also, identified was duplicate constipation therapy of Bisacodyl suppository prn and Dulcolax tabs prn; however, the medication profile did not specify which to take first. In addition, the medication profile indicated trazodone 50 mg 1 -2 tablets; however, it did not specify when to take 1 tablet versus 2 tablets. This was confirmed with the hospice clinical manager. In HSP HV #3, the hospice surveyor noted the medication profile indicated tamsulosin 0.8 mg 2 tabs daily; however, the actual dose was 0.4 mg 2 tabs daily. This was confirmed with the hospice clinical manager. Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain all clinical information. In HSP RR #6, the hospice surveyor noted there was no documentation of wound care provided on the third week of service only indicating the dressing was changed per order. This was confirmed with the clinical team lead.

Observed in Record Review. In 1 of 1 discharge records reviewed, the organization did not provide the hospital with a copy of the hospice discharge summary or a copy of the patient record. In HSP RR #8, the hospice surveyor noted the hospice services were revoked as the patient transferred to the hospital; however, the organization did not provide the hospital with a discharge summary. This was confirmed with the clinical team lead.

Observed in Record Review. In 1 of 4 discharged records reviewed, the organization did not create a discharge summary. In HSP RR #10, the hospice surveyor noted the organization did not create a discharge summary and notify the attending physician or its availability as evidenced by the organization was not able to produce this documented. This was confirmed with the clinical team lead.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not provide information on procedures to follow in an emergency or natural disaster. In HSP HV #3, the hospice surveyor noted the individualized emergency plan did not indicate the use of oxygen, assistive device usage of walker and wheelchair, and the treatment with the Pleurx. This was confirmed with the hospice clinical manager.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the organization did not take action to minimize identified safety and security risks. In HSP HV #1, the hospice surveyor noted the staff did not take action when oxygen cylinders were stored in closet with door close upright and uncrated at the time of the home visit. This was confirmed with the hospice clinical manager.