Every finding on record at Glacial Ridge Hospice

Based on interview, and document review, the agency failed to ensure a comprehensive medication review of all client prescription and over-the-counter medications was completed for 1 of 3 patients (P5) whose medications were reviewed, during a home visit. --- Findings Include:P5's Plan Of Care (POC) dated 3/16/26 to 6/13/26, identified P5's start of care date was 3/16/26, with a terminal diagnosis of acute kidney failure.  P5's visit orders included nursing once every week for thirteen weeks and twelve visits as needed (PRN).  P5's POC also included visit orders for aide visits once every week for thirteen weeks and seven PRN.  Nursing care plan included medication reconciliation. P5's Agency Medication Profile Report dated 4/27/26 identified the following:Olanzapine 10 milligrams (mg) oral tablet, take one tablet daily at bedtime for agitationDuring a home visit on 4/28/26 at 7:45 a.m., with home health aide (HHA)-A personal cares were observed in P5's skilled nursing facility (SNF) room.  P5's SNF Medication Review Report dated 4/28/26, obtained at 8:49 a.m. a current medication listing was obtained from the SNF licensed practical nurse., identified the following:Olanzapine (antipsychotic medication) oral tablet, give 5 mg by mouth one time a day for agitation. Dulcolax Rectal Suppository (Bisacodyl-stimulant laxative) insert 10 mg rectally as needed (PRN) for constipation every other day (QOD)During a phone interview on 4/29/26 at 9:30 a.m., registered nurse (RN)-A confirmed she was P5's nurse and reconciled P5's medication. RN-A stated her usual practice was to reconcile patient's medications every three months for their recertification or if a medication was added or changed. RN-A stated had thought P5's olanzapine was ordered when P5 was admitted and the Dulcolax order must have been added by the SNF from standing orders. RN-A indicated the SNF had not notified her of any new orders, and she relied on the SNF to notify her of changes, since RN-A did not have access to the SNF electronic medical records. RN-A stated it was important to reconcile P5's medications to assure right dosage and right medications were administered, and potential interactions could be harmful to P5. During interview on 4/29/26 at 11:53 a.m., hospice manager (HM)-A verified P5's medication orders were not reconciled with the SNF medication orders.  HM-A indicated expectation that patient medications would be reconciled to avoid medication errors. At 12:15 p.m., HM-A stated P5's olanzapine order was a transcription error during hospice admission, and the facility must have added the Dulcolax from their standing orders. The agency Medication and Treatment Management policy reviewed October 2025, identified the client's medical record would be monitored for potential drug interactions with each new certification period and with any new medication orders.  Nursing management of medications included verifying correct medications. At each routine visit, the nurse would ask the client if there were any new medications or changes in current medications.

Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 1 of 8 patients (P3) who received home health aide services and who's records were reviewed. --- Findings Include:P3's Plan of Care (POC) dated 3/31/26 to 6/28/26, identified P3 began hospice services on 3/31/26. PC had a terminal diagnosis of hypertensive heart disease with heart failure.  P3's visit orders included aide visits once every week for thirteen weeks and ten visits as needed (PRN). P3's POC also included nursing visits one every week for twelve weeks and twelve visits PRN.  P3's medical record identified P3 began aide services on 4/1/26. P3's registered nurse (RN) visits were completed on 3/31/26, 4/8/26, and 4/15/26. P3's RN visit notes identified aide supervision assessments were not performed. A phone interview was attempted on 4/29/26 at 9:15 a.m. and 11:20 a.m., with RN-B, but there was no answer. During interview on 4/29/26 at 11:55 a.m., hospice manager (HM)-A verified P3 had aide visits without RN supervision and identified her expectation was that RN visits would include supervision of aides as required. The agency Home Health Aide Supervision policy, reviewed/revised October 2025, identified all clients required supervision or monitoring of aide tasks within fourteen days after initiation of cares to determine if the home health aide was performing tasks and response of the client. The supervisory visit would be documented and if a deficiency in aide services was verified during the RN on-site visit, then the home health aide must complete retraining and a competency evaluation for the deficient and all related skills.

Based on interview and document review the agency failed to ensure 1 of 10 patients (P8) had a complete comprehensive assessment with the interdisciplinary group no later than 5 calendar days after the election of hospice care. --- P8s medical record identified P8 was admitted to hospice on 6/16/23, with malignant neoplasm of rectum (rectal cancer). P8s Medical Social Worker (MSW) Visit Note dated 6/26/23, identified P8s MSW initial assessment was completed 6/26/23, 10 days after hospice admission. During interview on 9/6/23 at 3:45 p.m., social worker (SW)-A confirmed P8s medical social worker initial assessment was completed 6/26/23, 10 days after hospice admission. SW-A stated she may have missed P8s initial assessment, because she had seen him for bereavement services prior to hospice admission. SW-A stated her usual process was to complete the patients initial assessments within five days of admission, and it was important to assess patients to ensure their needs were met. During interview on 9/7/23, at 2:28 p.m. hospice manager (HM)-A indicated it was her expectation that all patients received their initial comprehensive assessments with the interdisciplinary team within five days of admission. HM-A stated their medical record system alerted staff to complete patient initial assessments, by identifying them in red, to ensure they were completed timely. A policy was requested, but not provided.

Based on staff interview and record review the agency failed to ensure services were provided in accordance with the plan of care for 8 of 10 (P1, P2, P4, P5, P6, P8, P9, P10) patients reviewed who received volunteer services. --- The agency form titled Volunteer Hours reviewed from 6/1/23 to 9/6/23, identified the following: -P1 received volunteer services 7/13/23 -P2 received volunteer services 6/16/23, 7/14/23, 8/10/23, 8/16/23, and 8/18/23 -P4 received volunteer services 8/18/23, and 8/19/23 -P5 received volunteer services 6/11/23, 6/15/23, 7/20/23, and 8/17/23 -P6 received volunteer services 6/13/23, 7/14/23, 8/16/23, and 8/18/23 -P8 received volunteer services 6/23/23, 7/7/23, 7/20/23, and 8/18/23 -P9 received volunteer services 6/2/23, 6/16/23, 6/2923, 6/30/23, 7/14/23, 8/22/23, and 8/27/23 -P10 received volunteer services 6/2/23, 6/16/23, 6/30/23, and 7/14/23 P1s medical record identified P1 was admitted to hospice on 1/20/23, with aneurysm of aortic arch, without rupture (enlargement and weakening of the artery wall). P1s plan of care lacked discipline orders for volunteer services. P2s medical record identified P2 was admitted to hospice on 6/9/23, with degeneration of nervous system due to alcohol. P2s plan of care lacked discipline orders for volunteer services. P4s medical record identified P4 was admitted to hospice on 7/19/23, with Alzheimers disease with early onset. P4s plan of care lacked discipline orders for volunteer services. P5s medical record identified P5 was admitted to hospice on 5/11/23, with gastrointestinal hemorrhage (bleeding of digestive tract). P5s plan of care lacked discipline orders for volunteer services. P6s medical record identified P6 was admitted to hospice on 5/18/23, with Alzheimers disease. P6s plan of care lacked discipline orders for volunteer services. P8s medical record identified P8 was admitted to hospice on 6/16/23, with malignant neoplasm of rectum (rectal cancer). P8s plan of care lacked discipline orders for volunteer services. P9s medical record identified P9 was admitted to hospice on 2/17/23, with squamous cell carcinoma (skin cancer) of left lower limb, including hip. P9s plan of care lacked discipline orders for volunteer services. P10s medical record identified P10 was admitted to hospice on 5/22/23, with Alzheimers disease with late onset. P10s plan of care lacked discipline orders for volunteer services. During interview on 9/6/23, at 1:53 p.m. volunteer coordinator (VC)-A confirmed the above findings and stated volunteer services were not included on patients plan of care (POC), even if they received volunteer services. VC-A indicated volunteer services were discussed during interdisciplinary team (IDT) meetings. During interview on 9/6/23, at 3:10 p.m. hospice manager (HM)-A confirmed the above findings. HM-A indicated the agencys usual practice was to include volunteer services as needed on the patients initial POC identified as needed, but not on the current POC. HM-A stated VC-A discussed volunteer services during IDT meetings. HM-A indicated it was important services were identified on patients POC, so everybody knew the services received. During a follow up interview on 9/7/23, at 2:28 p.m. HM-A indicated she felt it was not necessary to include volunteer services in patients POCs because they were discussed during IDT meetings, and the medical director was made aware. HM-A stated they had included volunteer services when they used their previous electronic record system, but they did not with their current electronic record system due to difficulties with scheduling the volunteer services in the system. The agency policy titled GRHS Hospice Services revised 10/22, identified plan of care and services provided were individualized based on a patients individual needs and adjusted accordingly. The policy further identified the patient and/or family members were included in the initial assessment in the building of the plan of care to insure understanding of what hospice services were provided.