Every finding on record at Horizon Health Hospice

Based on interview and document review, the hospice agency's interdisciplinary group failed to review, revise and document the plan of care no less than every 15 calendar days for 3 of 11 patients (P2, P6, P11) whose records were reviewed. --- Findings include: P2’s admission profile printed 3/4/26, indicated P2 was admitted to hospice services on 11/20/25, with primary diagnosis of chronic obstructive pulmonary disease (COPD). P2’s patient chart indicated IDG review was completed on the following dates: 12/17/25, 12/31/25, 1/14/26, 1/28/26, 2/11/26, 2/25/26. However, P2’s chart lacked evidence IDG review had been completed no less than every 15 calendar days from 11/20/25 through 12/17/25. P6’s admission profile printed 3/4/26, indicated P6 was admitted to hospice services on 12/30/25, with primary diagnosis of atherosclerosis heart disease of native coronary artery (restricting blood flow and oxygen to the heart muscle). P6’s patient chart indicated IDG review was completed on the following dates: 1/14/26, 2/11/26, and 2/25/26. However, P6’s chart lacked evidence IDG review had been completed no less than every 15 calendar days from 1/14/26 through 2/11/26. P11’s Hospice Plan of Care and Certification of Terminal Illness, for certification period 12/15/25 to 2/12/26, indicated P11 was admitted to hospice services on 12/20/24, with primary diagnosis of Alzheimer’s disease. P11’s patient chart indicated P11 was discharged from hospice services on 2/5/26. P11’s patient chart indicated IDG review was completed on the following dates: 1/2/25, 1/15/25, 1/29/25, 2/12/25, 2/26/25, 3/12/25, 3/26/25, 4/9/25, 4/23/26, 5/7/25, 5/21/25, 6/4/25, 7/2/25, 7/16/25, 7/30/25, 8/13/25, 8/27/25, 9/10/25, 9/24/25, 10/7/25, 10/23/25, and 11/5/25. However, P11’s chart lacked evidence IDG review had been completed no less than every 15 calendar days from 6/4/25 through 7/2/25. Additionally, P11’s chart lacked evidence IDG review had been completed after 11/5/25 through P11’s discharge on 2/5/26. On 3/4/26 at 1:05 p.m., the agency director (AD) verified patient charts lacked evidence that IDG reviewed, revised, and documented the plan of care no less than every 15 calendar days for P2, P6, and P11. AD stated IDG review needed to be completed no less than every 15 calendar days, and the nurse was expected to note the IDG meeting in the patient’s chart. AD stated IDG meetings were important to ensure all disciplines were “on the same page”, the patient was receiving all the services required, and the medical director was aware of everything. The agency’s Interdisciplinary Group Meeting policy, updated 3/7/25, indicated the IDG reviews each patient’s plan of care every two weeks, or more frequently if needed, to continually monitor the care and services provided to the patient and his/her continued eligibility for hospice care.

Based on interview and document review, the agency failed to ensure ongoing communication and coordination of services for 1 of 3 hospice patients (P10) who were observed during agency home visits. --- Findings include: P10’s Hospice Plan of Care and Certification dated 1/14/26, indicated P10 was admitted 5/19/25 and diagnoses included Alzheimer’s disease and generalized anxiety disorder. P10’s assisted living facility (ALF) Medications – Current list printed 3/4/26, indicated the ALF assumed care of P10 on 1/28/26, and indicated the following medication orders that did not match the hospice agency’s records:Lorazepam 0.5mg - Give 1 tab by mouth or sublingually every 4 hours as needed for anxiety or agitationTylenol suppository (acetaminophen) 650mg in rectum every 4 hours as needed for pain or mild to moderate fever >100.5 or symptoms of discomfort. Administer if unable to take Tylenol by mouth.Zofran (ondansetron) 8mg by mouth every 6 hours as needed for nausea However, P10’s hospice agency Medication Profile, printed 3/4/26, indicated the following:Lorazepam 0.5mg - Give 2 tabs by mouth every 4 hours as needed for anxiety and agitationNo Tylenol suppository order indicated on hospice agency medication profileNo Zofran order indicated on hospice agency medication profile On 3/4/26 at 12:15 p.m., registered nurse (RN)-B verified an order for Zofran (ondansetron) was not listed on the agency’s record. RN-B stated medication reconciliation was completed with each hospice recertification, and if any discrepancies were found, the nurse followed-up with the Medical Director. RN-B stated P10 recently moved from another facility to the current ALF, and a medication reconciliation had not been completed following the facility transfer. RN-B stated it was important that the facility and hospice medication records matched so when the facility staff contacted hospice with concerns, both had the same information so hospice could provide accurate information. On 3/4/26 at 1:05 p.m., the agency director (AD) stated nurses were expected to reconcile medications between the facility and hospice every time they visited the patient to check for changes and ensure accuracy. AD stated it was important for the facility and hospice medication records to match so the on-call hospice nurse has accurate information to triage calls from the facility and to prevent potential for “huge” medication errors. Additionally, AD stated nurses were expected to reconcile medications when a patient moves from one facility to another. The agency’s Coordination of Services policy updated 3/7/25, indicated the assigned hospice RN coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness. The agency’s Medications-Profile policy, updated 3/7/25, indicated a patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days.

Based on observation, interview and document review, the facility failed to implement the necessary infection control practices for 1 of 3 patients (P9) during agency home visit observations. --- Findings include: P9’s Admission Profile dated 3/4/26, indicated P9 was admitted 2/18/26, and diagnoses included multiple myeloma (cancer of the plasma cells), Alzheimer’s disease, and congestive heart failure (CHF). During a home visit observation on 3/3/26 at 10:15 a.m., Home Health Aide (HHA)-A walked to the corner of P9’s room and placed her backpack directly on the seat of a beige, metal folding chair. However, HHA-A failed to place a barrier between the backpack and P9’s chair. On 3/3/26 at 10:37 a.m., HHA-A stated she placed her backpack on the patient’s folding chair to make sure it was “set out of the way so no one trips”. HHA-A confirmed she had not placed a barrier between the backpack and the patient’s chair. On 3/4/26 at 1:05 p.m., the agency director (AD) stated staff were expected to keep their clinical bag off the floor and off any of the patients’ belongings, unless a barrier was placed between the two items, during home visits. AD stated the protocol was in place to prevent the transmission of infection and was reviewed during staff orientation. On 3/4/26 at 1:05 p.m., the AD stated the agency did not have a specific policy in place regarding infection control prevention related to agency staff clinical bags.

Based on interview and record review, the agency failed to ensure registered nurse (RN) supervisory visits were made at least every 14 days for 5 of 8 patients (P3, P4, P7, P8, and P10) in the sample who received home health aide (HHA) services. --- P4 was admitted for hospice services on 1/15/26, with diagnoses of stage 4 chronic kidney disease, epilepsy, and type 2 diabetes. The plan of care and certification of terminal illness for the period 1/15/26 to 3/15/26, indicated P4 received skilled nursing services 1 visit weekly, and home health aide (HHA) services 2 times weekly. P4's first HHA visit occurred 1/16/26. Review of P4's supervisory visits indicated supervisory visits were completed 2/9/26 and 2/27/26.  Findings include: P3 was admitted for hospice services on 12/31/25, with diagnoses of dementia, heart disease and hypertension. The plan of care and certification of terminal illness for the period 12/31/25 to 3/30/26, indicated P3 received skilled nursing services 2 visits weekly and as needed, P3 also received home health aide (HHA) services 2 times weekly. P3's first HHA visit occurred 1/2/26. Review of P3's supervisory visits indicated there was one supervisory visit completed on 3/2/26.  P7 was admitted for hospice services on 12/2/25, with diagnoses of end stage renal disease, chronic kidney disease, acute kidney failure, and hypertension. The plan of care and certification of terminal illness for the period 12/2/25 to 3/1/26, indicated P7 received skilled nursing services 2 times weekly and HHA services 2 times weekly. P7's first HHA visit occurred 12/5/25. Review of P7's supervisory visits indicated a supervisory visit was completed on 1/27/26 and 2/27/26. P8 was admitted for hospice services on 4/30/25, with diagnoses of congestive heart failure, hypertensive chronic kidney disease, diabetes, and chronic kidney disease stage 3. The plan of care and certification for the period 2/24/26 to 4/24/26, indicated P8 received skilled nursing services 2 times weekly and HHA visits weekly. Review of P8's supervisory visits November 2025 to February 2026, indicated a supervisory visit completed on 11/24/25 with the next supervisory visit completed on 12/16/25, the next supervisory visit did not occur until 1/7/26.  P10 was admitted to hospice services on 5/19/25, with diagnoses of Alzheimer's disease, cerebral infarction, anxiety and dementia. The plan of care and certification for the period 1/14/26 to 3/14/26, indicated P10 received skilled nursing services 2 times weekly and HHA visits 2 times weekly. Review of P10's supervisory visits November 2025 to February 2026, indicated supervisory visits were completed on 11/3/25, 12/17/25, 1/7/26, and 1/14/2, no further supervisory visits have been completed since 1/14/26 despite continued HHA visits 2 times weekly.  When interviewed on 3/4/26 at 1:05 p.m., registered nurse/agency director (AD) stated the expectation for supervisory visits was every 2 weeks. The computer system asked the nurse if they wanted to complete a supervisory visit at each visit, however, the system did not alert the nurse that a supervisory visit was due. AD reviewed identified patients' supervisory visits, AD indicated that there were gaps as noted in each of the identified patients. AD stated supervisory visits were important to ensure the HHAs were competent in their ability, and as accountability, HHAs were unlicensed staff, needed to ensure they were competent and safe to complete their jobs.  Agency Hospice Aide Supervision Policy dated 3/7/25, indicated a registered nurse made an on-site visit to the patients home no less than every 14 days to ensure that the services ordered by the interdisciplinary group and provided by the hospice aide were meeting the patients' needs. The supervisory visits were documented in the patients' clinical record every 2 weeks and included notations regarding the aide's competency, whether the aide followed the patients plan of care, and was satisfactory to the patient/family.

Based on interview and document review, the agency failed to document the cost savings achieved through the use of volunteers. This practice had the potential to affect all hospice patients. --- Findings include: Review of the agency’s volunteer records did not identify documented cost savings since 2023. On 3/4/26 at 10:51 a.m., the volunteer coordinator (SS)-A stated the documentation of volunteer cost savings was completed by the agency’s licensed social worker. On 3/4/26 at 11:32 a.m., the licensed social worker (SS)-B stated the documentation of volunteer cost savings was not completed by him. On 3/4/26 at 1:05 p.m., the agency director (AD) verified no cost savings had been documented for volunteer use for 2024 and 2025. The agency’s Volunteers – Services policy updated 3/7/25, indicated the volunteer coordinator maintains records of volunteer activity and records levels of volunteer participation and cost savings on a monthly and annual basis.