Every finding on record at Hospice of Michigan

Based on record review and interview, the Hospice agency failed to provide for the continued management of pain and symptoms for 1 (P-1) of 1 terminally ill patient who was discharged for cause without adequate discharge planning, resulting in the potential for decline in physiological functioning, unrelieved symptomology, lack of needed resources for continued hospice needs and overall unmet care needs at the end of life.  Findings include: --- Policy: Discharges, NO 0980, Effective date 02/01/2020 stated, "Before the patient can be discharged for cause, (Agency) will: Advise the patient that a discharge for cause is being considered; Make a serious effort to resolve the problem(s) caused by the patient's behavior or the situation; Document in the patient's clinical record the problem(s) and the efforts made to resolve the situation..., Prior to discharge, the (Agency) obtains a physician's discharge order from the (Agency) Medical Director and consults with the patient's community attending physician, documenting his or her review of the discharge decision in the discharge note."Patient #1 (P-1)’s start of care was 5/2/24.  The benefit period of review was 12/23/25 through 2/13/26 with terminal diagnoses that included Senile Degeneration of the Brain and Dementia.  The clinical record review was conducted on 3/25/36 at 12:30 p.m. and revealed the following:  The Plan of Care ordered Skilled Nursing (SN), Spiritual Care (SC), Hospice Aide (HHa), Music Therapy (MT) and Medical social Work (MSW) services to be provided. During the record review, it was noted that the patient (P-1) required the use of supplemental oxygen (as needed), had an indwelling urinary (Foley) catheter and had multiple pressure sores.  The Nursing Comprehensive Reassessment dated 12/2/25 revealed that P-1 had an indwelling (Foley) urinary catheter, was bedbound, experienced tremors, was totally dependent on others for ADL (activities of daily living) care, experienced pain and weakness, presented with pressure ulcers and received narcotic pain medications for management of pain and deemed terminally ill with a life expectancy of 6 months or less. A Coordination Note dated 12/30/25, authored by the Registered Nurse (Staff-C) revealed the patient’s daughter was upset about the SN visit being delayed.  The note reflected the patient’s daughter’s (FM #1) use of inappropriate language during a telephone call, as she requested to know what time the nurse and HHa would be arriving.  The note reflected FM #1’s anger towards Staff-C regarding inappropriate wound care and time spent with P-1 during visits. Staff-C did not make the visit in light of the inappropriate verbal interaction.  Further review revealed that there was no information provided to P-1 or FM #1 regarding the possibility of being discharged for cause based on these inappropriate acts.  A Hospice Nursing Clinical Note dated 1/2/26 documented, FM #1 expressed a lot of frustrations regarding frequently changing nurses and no nurse visit during the afternoons.  A Missed Visit note dated 1/2/26 documented, “Patient/Representative refused care; Daughter reports that she doesn’t understand why we have such incompetent nurses..., I’m just giving them constructive criticism..., FM #1 inquired about the time hospice nurses spend with the patient and requests more time. Will follow up with a joint visit next week."  A Nursing note dated 1/17/26 documented, FM #1 requested visit due to leaking catheter and medical supplies. A Nursing visit note dated 1/21/26 documented, FM #1 states understanding but is speaking loudly and screaming at patient during teaching.  A Coordination Note dated 2/1/26 documented, “She (patient’s daughter/FM #1) expressed frustration with constant trips to the drug store for meds and items not ordered by RN...” A Coordination Note dated 2/7/26 documented that during a telephone call, the patient’s daughter was upset that a scheduled visit did not occur and that nurse asked if the hired help that was present, if they were trained to do wound care. The note further documented that the patient’s daughter yelled in the background and stated, asking these types of questions was not my (nurse’s) job. Caregiver (CG) instructed the nurse not to come to the home.  The call was concluded.  A Coordination Note dated 2/10/26, via telephone, documented patient’s daughter was upset that P-1 did not receive a visit on Friday. The note further documented that FM #1 was very frustrated and mentioned that she would like to possibly switch hospice. Would like a call back, and to know if her mom (P-1) will be receiving a nurse visit before Friday.  A Coordination Note dated 2/17/26 (after the patient was discharged for cause), authored by the Administrator (Staff-A) documented, “Received call from FM #1 to discuss her concern and answer any clarifying questions regarding the discharge for cause completed on 2/13/26. FM #1 became upset during the call placing blame on hospice staff. I explained the process of discharge for cause and used active listening to hear her concerns.”  During review of the record, there was no documented evidence that information regarding discharge for cause was provided to P-1 or FM #1 prior to the actual discharge. On 3/26/26 at 10:30 a.m., during an interview, the Operational Manager of Detroit, (Staff-B) reported, "Staff was feeling unsafe going to see P-1 by themselves. There were manipulation and verbal threats.  There was one incident that almost became physical.  On 11/28/25, one of our nurses (Staff-E) was chased out to her car.” (There was no documented evidence in the clinical record to support that Staff-E was chased outside of the P-1's home enroute to her car). I documented it in a Hospice Nursing Clinical Note.”  (The referenced Nursing note dated 11/28/25 documented that the FM #1 told the nurse to get out of her house).  When asked if local authorities had been notified of the alleged incident or if any other action was taken at that time, Staff-B responded, “No. There was no action taken. We didn’t call the police or fill out an incident report, I just removed her (Staff-E) from the situation, then I assigned (Staff-C) to the P-1's case.”  When asked why the local authorities had not been notified due to the severity of the incident, Staff-B responded, “I didn’t do anything because it didn’t become physical.  I put Staff-C in there because she was more comfortable.  The other nurse's (Staff-E) personality is flat.  She’s not that easy to get along with. I just didn’t want to assume the incident was FM #1's fault.” When asked why the patient was discharged from the agency’s services, Staff-B reported, “Due to personal safety concerns with FM #1.”  When asked if there were any direct concerns with the actual patient (P-1), Staff-B responded, "No. Only P1's daughter."  When asked if the P-1's Physician was notified prior to her being discharged for cause on 2/13/26, Staff-B said, “Yes. I called his (P-1's physician) office and told them about the discharge. It was on the same day, 2/13/26 at 2:50 p.m. I spoke with the person at the front desk because P-1's physician wasn’t available.” There was no evidence that Staff-B directly informed P-1's physician of the intent to discharge in advance of the discharge for cause on 2/13/26.When asked if the Medical Director (Staff-F) was notified prior to discharging the patient for cause, Staff-B stated, “No, not prior to 2/13/26.” When asked if the order to discharge for cause was written/given prior to 2/13/26, Staff-B said, “No. I had a discussion with the Quality Team that morning about the plan to discharge. We were just looking at the case from an outside perspective.  I was instructed to discharge for cause by the people in that meeting.”  When asked if P-1 was informed of the decision to discharge for cause prior to 2/13/26, Staff-B said, “No. I didn’t feel comfortable informing her of a possible discharge because of FM #1's behavior.” When asked if P-1 was provided with assistance or referrals to another hospice agency prior to the date of discharge, Staff-B stated, “No. Not prior to the discharge.”  When asked who completed the discharge summary, Staff-B responded, “I did.” When asked if there was a specific sentinel event that occurred that resulted in the immediate decision to discharge P-1 for cause, Staff-B reported, “No. Just things that had been occurring over time.”  On 3/26/26 at 11:46 a.m., during an interview, (Staff-C) reported, “I got P-1 after her previous nurse.  Staff-E did one visit, then she (P-1) was assigned to me around December. FM #1 was very aggressive and mean at times.  She was upset that the previous case manager was no longer her case manager.  I informed her that we would maintain visits at 2x/wk.  The 1st visit, she was fine.  She always compared me to the previous case manager.  FM #1 did inform me that she was Bi-polar.  She would be screaming and yelling in general.  She’d get aggressive with me if she’d ask me to do something that was outside of the plan of care.  She got upset when I wasn’t able to “dig her mom out” (removal of fecal impaction) due to FM #1's mom/P-1 being constipated.  FM #1 would just blow up, pulling her hair, etc. She was verbally abusive towards me, for example, I was late coming to a visit.  She asked me why I would only be at the visit for an hour.  She wanted more time.  She wanted me to sit and stay a while with P-1.”  When asked of her awareness about P-1 being discharged for cause, Staff-C stated, “We had to go in front of a panel and talk about why we wanted to discharge for cause. The panel was called the Complex Case Committee review.  (Staff-B) was there. We had the meeting on the same day that P-1 was discharged for cause. There was one incident where I had to pull over because I was upset at how FM #1 was talking to me, so I decided not to make the visit that day.”  When asked if she ever informed FM #1 that her mother (P-1) could be discharged for cause, Staff-C said, “No.  I felt uncomfortable providing care if FM #1 was present. I also felt that the P-1 was unsafe.”  When asked if she notified the local authorities if she felt that P-1 was unsafe, Staff-C stated, “No. I didn’t. I never saw her hit her mother, just occasionally yelling at her.” When asked if the Social Worker had been notified to assess the patient in light of the alleged family dynamics, Staff-C reported that Staff-B notified the Social Worker, however, there were no Social Work visit notes that addressed any of the above alleged concerns.  On 3/26/26 at 1:15 p.m., an interview was conducted with the Administrator (Staff-A) who reported, “We care for a lot of patients. Very rarely do we have a discharge for cause."  When asked why the patient was discharged for cause, Staff-A reported, “Immediate safety concerns towards staff; Not from the patient, but from her family member (FM #1).”  When asked if the local authorities had been notified of the alleged safety concerns and reported threatening behavior, Staff-A responded, “No. We started 2-person visits. Eventually it came to staff feeling uncomfortable going into the patient’s home.” When asked if P-1's Physician was notified prior to the discharge, Staff-A said, “No. As far as I know, it was not until the day of discharge on 2/13/26.” When asked if there was a written order to discharge for cause by the Medical Director before 2/13/26, Staff-A said, “No. Not that I know of.”  Staff-A further stated, “There was a meeting with the Quality Compliance Department.  We would never discharge for cause without having a meeting with them.  At that point the decision was made to discharge after a chart audit.”  When asked Who made the decision to ultimately discharge P-1 for cause, Staff-A stated, “The Compliance Director.”  When asked if the Medical Director was part of the compliance committee, Staff-A stated, “No, but she’s part of the IDG (Interdisciplinary Group) team.”  When asked what, if any assistance was provided to P-1 to ensure continuity of care, specifically assistance with hospice placement, Staff-A reported, “I believe FM #1 was given a list of resources to call.  I’d have to check.”   The Hospice Discharge Summary dated 2/13/26 documented “Called Daughter to inform her of the decision at 1507 with (Member of Quality Team). We informed P-1's daughter, that effective immediately, hospice services ended today due to discharge for cause. We called P-1's primary care physician and let them know. We informed P-1's daughter that she will be receiving a letter via email and mail stating all this and that if she needs any resources, we can provide them. FM #1 became upset making accusations about the care in the home and saying that we are "abandoning" her and her mom along with that we are an unethical company. FM #1 stated plans on suing. FM #1 began to ask questions regarding care. That she "did not do anything wrong in the past week."  Informed FM #1 that it was a decision made by the company that we can no longer provide care and that P-1 is being discharged for cause.” A letter on file, dated 2/13/26 was addressed to P-1's daughter (FM #1) and documented, “Thank you for trusting (Hospice Agency) with the care of your mother, (P-1).  Due to a deviation from the agreed-upon plan of care or an unsafe environment for hospice staff, (Hospice Agency) will no longer be providing hospice services to P-1, effective February 13, 2026. If you have any questions regarding this letter, please contact me at (provided number).  Sincerely, (Staff-B) Manager, Clinical Services, (Hospice Agency).” Upon review of the clinical record, it was determined that the agency failed to follow its own policy regarding the requirements for discharge for cause.  The patient was not given advance notice of the decision to discharge for cause; There were no documented efforts to resolve the concerns to ensure the patient received ongoing needed hospice services;  The hospice failed to inform the patient’s Physician of the decision to discharge for cause prior to being discharged; The agency failed to ensure the Medical Director was informed, and provided a written order for discharge, prior to the discharge for cause, and failed to ensure the patient received appropriate discharge planning including resources for other hospice agencies to meet continuing hospice care needs at the end of life, prior to being discharged. The Administrator reviewed and acknowledged these findings during the above interview on 3/26/26 at 1:15 p.m.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group supervised the provision of care and services for 1 (P-1) of 3 records reviewed, resulting in the potential for unmet care needs for these patients. Findings include: --- Patient #1’s (P-1) Start of Care (SOC) was dated 5/2/24. The Plan of Care (POC) identified a terminal diagnosis of Senile Degeneration of Brain. During record review on 3/26/26, it was noted that the InterDisciplinary Group (IDG) Meeting Review dated 12/31/25 stated, “Nursing: 2 x week for 9 weeks starting 12/23/25… (PRN (as needed)) 6 visits starting 12/23/25.” On 1/6/26, Staff-C (Registered Nurse/Case Manager) stated, “Summary: Joint visit with Staff-B (Operations Manager/Registered Nurse) and Staff-D (Hospice Aide)… Staff-B with daughter for most of visit providing education and addressing concerns…” On 1/7/26, Staff-C completed a Physicians Order stating, “Nursing 1 x week for 7 weeks starting 1/7/26.” Staff-B was interviewed on 3/26/26 at 10:30am and questioned regarding the 1/6/26 visit and stated, “Yes, reducing the nursing visit frequency was discussed with the daughter to 1 time weekly. The second visit was unnecessary and more of companionship. The daughter agreed to the plan to have the nurse 1 time weekly and the nurse to call later in the week to see if a visit was necessary. No, the discussion with the daughter is not documented within the clinical record, I did not put a note in for that joint visit. No, it was not documented about the discussion to decrease the frequency.” There was no documented evidence in the record as to a reason for decreasing nursing visits. On 1/15/26, it was noted that the IDG Meeting Review stated, “Meeting Notes: RNCM (Registered Nurse Case Manager) (Staff-C): Joint visit this week with HHA (Home Hospice Aide) and MSW (Medical Social Worker). Much education provided during the visit: foley care and maintaining skin integrity. Discussed the possibility of increasing VF (visit frequency) for support – will discuss with dau (daughter).” (SIC) The record contained no evidence of increased visit frequency for any discipline. Furthermore, on 2/4/26, the MSW documented, “SW (social worker) made call the pt’s dau (daughter) to schedule February visit. She did not answer. SW left voicemail message with offer for visit this afternoon or next Tuesday. SW requested return call and provided contact information.” Staff-B was interviewed on 3/26/26 at 10:30am and questioned regarding the MSW documentation and stated, “I don’t see anything after that 2/4/26 phone call.” The medical record contained no documented evidence of the MSW attempting to contact the daughter to complete the February visit up to the discharge on 2/13/26. The IDG failed to supervise and ensure the provision of nursing care services.A review of the agency policy occurred on date titled "Interdisciplinary Team Meeting" (Effective Date: 2/3/2020). The policy states, "Policy: The Interdisciplinary Team (IDT) will meet in person to review, discuss and revise patient care objectives. Through the process of exchanging information among the IDT, patient and family care needs will be reviewed and revised to meet outcomes. These reviews will be documented in the electronic medical records as part of the IDT meeting.”A review of the agency policy occurred on date titled "Coordination of Services" (Effective Date: 3/27/17). The policy states, "Policy: The Interdisciplinary Team (IDT) ensures that there is a coordinated and effective exchange of information between all disciplines, with all contracted service providers and in all care settings.”

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. 13 of 27 (48%) clinical records reviewed revealed that the agency did not ensure that the interdisciplinary group completed an initial comprehensive assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 6: The patient elected hospice care on 03/05/2025 with a diagnosis of cerebrovascular disease. The registered nurse completed a comprehensive assessment on 03/05/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker documented a missed visit note on 03/06/2025 and completed a psychosocial assessment on 03/24/2025 that included documentation reflecting the assessment of the patient's psychosocial and emotional needs (19 days). The spiritual care coordinator completed a missed visit note on 03/06/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's psychosocial and spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 7: The patient elected hospice care on 03/19/2025 with a diagnosis of heart disease. The registered nurse completed a comprehensive assessment on 03/19/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. A social worker documented a missed visit note on 03/20/2025. The spiritual care coordinator completed a missed visit note on 03/20/2025 and completed a spiritual assessment on 03/21/2025 that included documentation reflecting the assessment of the patient's spiritual needs. The clinical record lacked documentation that a comprehensive assessment that included the patient's psychosocial and emotional needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 9: The patient elected hospice care on 03/05/2025 with a diagnosis of cerebrovascular infarction. The registered nurse completed a comprehensive assessment on 03/05/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker documented a missed visit note on 03/06/2025 and completed a psychosocial assessment on 03/11/2025 that included documentation reflecting the assessment of the patient's psychosocial and emotional needs (6 days). The spiritual care coordinator completed a missed visit note on 08/11/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs and psychosocial/emotional needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 10: The patient elected hospice care on 04/28/2025 with a diagnosis of chronic systolic heart failure. The registered nurse completed a comprehensive assessment on 04/28/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker completed a psychosocial assessment on 04/30/2025 that included documentation reflecting the assessment of the patient's psychosocial and emotional needs. The spiritual care coordinator completed a missed visit note on 04/29/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 13: The patient elected hospice care on 03/28/2025 with a diagnosis of myelodysplastic syndrome. The registered nurse completed a comprehensive assessment on 03/28/2025 that included documentation reflecting the assessment of the patient's physical, psychosocial, emotional, and bereavement needs. The spiritual care coordinator completed a missed visit note on 03/31/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 14: The patient elected hospice care on 11/21/2025 with a diagnosis of malignant neoplasm of the colon. The registered nurse completed a comprehensive assessment on 11/21/2025 that reflected the assessment of the patient's physical, psychosocial, emotional, and bereavement needs. The spiritual care coordinator completed a missed visit note on 11/25/2025 and completed a spiritual assessment on 12/01/2025 (10 days). The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 15: The patient elected hospice care on 04/18/2025 with a diagnosis of malignant neoplasm of breast. The registered nurse completed a comprehensive assessment on 04/18/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker completed a psychosocial assessment on 04/23/2025 that included documentation reflecting the assessment of the patient's psychosocial and emotional needs. The spiritual care coordinator completed a missed visit note on 04/21/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 16: The patient elected hospice care on 02/06/2025 with a diagnosis of chronic obstructive pulmonary disease. The registered nurse completed a comprehensive assessment on 02/06/2025 that included documentation reflecting the assessment of the patient's physical, psychosocial, emotional, and bereavement needs. The spiritual care coordinator completed a missed visit note on 02/10/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 17: The patient elected hospice care on 11/10/2025 with a diagnosis of heart failure. The registered nurse completed a comprehensive assessment on 11/10/2025 that included documentation reflecting the assessment of the patient's physical, psychosocial, emotional, and bereavement needs. The spiritual care coordinator completed a missed visit note on 11/13/2025. The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 18: The patient elected hospice care on 09/09/2025 with a diagnosis of malignant neoplasm of the uterus. The registered nurse completed a comprehensive assessment on 09/09/2025 that included documentation reflecting the assessment of the patient's physical, psychosocial, emotional, and bereavement needs. The spiritual care coordinator completed a missed visit note on 09/12/2025 and completed a spiritual assessment on 10/24/2025 (55 days). The clinical record lacked documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 19: The patient elected hospice care on 09/06/2025 with a diagnosis of malignant neoplasm of the left breast. The registered nurse documented a comprehensive assessment on 09/06/2025 that included documentation reflecting the assessment of the patient's physical, psychosocial, and bereavement needs. The spiritual care coordinator completed a missed visit documentation for 09/11/2025 and completed a spiritual assessment on 09/12/2025 (6 days). The clinical record lacks documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 25: The patient elected hospice care on 03/18/2025 with a diagnosis of liver cell carcinoma. The registered nurse documented a comprehensive assessment on 09/09/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker documented a psychosocial assessment on 04/24/2025 (37 days). The spiritual care coordinator documented a missed visit for 03/20/2025. The clinical record lacks documentation that a comprehensive assessment that included the patient's psychosocial, emotional, and spiritual needs was completed no later than 5 days after the election of hospice care. CLINICAL RECORD 26: The patient elected hospice care on 02/03/2025 with a diagnosis of amyotrophic lateral sclerosis. The registered nurse completed a comprehensive assessment on 02/03/2025 that included documentation reflecting the assessment of the patient's physical and bereavement needs. The social worker completed a psychosocial assessment on 02/07/2025 that included documentation reflecting the assessment of the patient's psychosocial and emotional needs. The spiritual care coordinator completed a missed visit note on 02/05/2025. The clinical record lacks documentation that a comprehensive assessment that included the patient's spiritual needs was completed no later than 5 days after the election of hospice care. During an interview and joint record review on 01/08/2026, the Administrator (Personnel Record 7) confirmed that clinical records 6, 7, 9, 10, 13, 14, 15, 16, 17, 18, 19, 25, and 26 did not include documentation that a comprehensive assessment including psychosocial, emotional, and spiritual assessment was completed no later than 5 calendar days after the election of hospice care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview and observation. In 2 of 6 (33%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated in accordance with the agency's policy. DOCUMENT 1: Policy: "Infection Control: Standard Precautions & Personal Protective Equipment" (effective date: 08/01/2020) read in part, "Key situations where hand hygiene should be performed include: If hands will be moving from a contaminated body site to a clean body site during patient care and after glove removal." DOCUMENT 1: Wound dressing applications read in part, "Remove the old dressing carefully. Discard the soiled dressing in the sealable waterproof trash bag, remove and discard your soiled gloves, perform hand hygiene, put on new gloves." HOME VISIT 1: The patient elected hospice care on 12/06/2024 with a diagnosis of unspecified dementia. During the observed home visit, the hospice aide (Personnel Record 1) was observed providing a bed bath. The hospice aide was observed providing peri-care. After providing peri-care, the hospice aide removed soiled gloves and donned a new pair of gloves without performing hand hygiene. HOME VISIT 3: The patient elected hospice care on 09/12/2025 with a diagnosis of Alzheimer's disease. During the observed home visit, the registered nurse (Personnel Record 3) was observed performing wound care to the patient's left heel. The nurse donned gloves, removed the soiled dressing, cleansed the heel with wound cleanser, patted the wound area dry with gauze pads, applied an iodine pad, and covered it with a foam dressing. The nurse did not change gloves and perform hand hygiene after removing the soiled dressing. During an interview on 01/07/2026, the Administrator (Personnel Record 7) confirmed the findings and validated the agency policy that hands should be cleansed between and after glove removal and after removal of a soiled dressing.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. The competency evaluation addresses each of the following subject areas: they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 4) The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation. 5)The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. AND 6) A hospice aide is not considered competent in any task for which he or she is evaluated as “unsatisfactory.” (L618) 7)The hospice maintains documentation that demonstrates the requirements of competency evaluation are met (items 3-5 above). This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) hospice aide personnel records the agency did not ensure the hospice aide completed a competency evaluation prior to independent assignment to patient care. PERSONNEL RECORD 1 : The hospice aide's date of hire was 04/16/2024. The personnel record contained no evidence of a completed competency assessment upon hire. The personnel record contained a documented annual "Hospice Aide Joint Supervisory Evaluation Visit" but not an initial competency assessment demonstrating that every skill was verified by a registered nurse. The Statewide Director of Quality reported in an interview on 01/09/2026, "We will learn from this, we do not have a general competency assessment for aides on hire with all the elements. We just do the annual on-site." The annual on-site evaluation form did not include all of the required task elements to be evaluated.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the HA. CLINICAL RECORD 1: The patient elected hospice care on 12/06/2024 with a diagnosis of unspecified dementia. The plans of care effective 10/02/2025-11/30/2025 and 12/01/2025-01/29/2026 ordered HA services twice (2) weekly beginning 10/02/2025. The HA visits were provided as ordered. The HA supervisory visits were conducted on 10/31/2024 and 11/18/2025 (18 days), and 11/28/2025 and 12/18/2025 (20 days). CLINICAL RECORD 14: The patient elected hospice care on 11/21/2025 with a diagnosis of malignant neoplasm of the colon. The plan of care, effective 11/21/2025-02/18/2026, ordered HA services once (1) weekly beginning 11/25/2025. The HA visits were provided as ordered. The HA supervisory visits were conducted on 12/15/2025 and 12/30/2025 (15 days), and 11/28/2025 and 12/18/2025 (20 days). In a joint record review and interview on 01/07/2026, the Administrator (Personnel Record 7) confirmed that HA supervisory visits were not completed every 14 days.

Based on record review and interview, the agency failed to ensure nursing services were promptly provided to meet patient needs following a significant change in status in 1 (P-1) of 1 record reviewed with a significant change in status, from a total of 3 records reviewed, resulting in the patient experiencing unrelieved pain at end of life (see L591). --- .

Based on record review and interview, the agency failed to ensure nursing services were promptly provided to meet patient needs following a significant change in status in 1 (P-1) of 1 record reviewed with a significant change in status, from a total of 3 records reviewed, resulting in the patient experiencing unrelieved pain at the end of life. Findings include: --- **Policy titled ";Nursing Services" (effective 3/27/2017) stated, ";Nursing services will be available twenty-four (24) hours a day, seven (7) days a week." **Policy titled ";Medication – Management" (effective 3/27/2017) stated the following: ";2. Medications are provided on a timely basis and are available 24 hours a day and 7 days a week, as needed." ";4. If the medication needed for an emergent need is contained in the contents of the Comfort Pak, HOM/AH physicians my dispense a Comfort Pak through HOM/AH physician stock to address the immediate need." P-1: This 56-year-old patient was admitted to Hospice on 7/23/24 with the terminal diagnosis of squamous cell carcinoma (skin cancer) with metastases to the head and neck. During record review on 9/18/24, it was noted in the triage communication notes P-1's wife called triage on 7/27/24 at 4:32 PM to report the patient was in urgent need of more morphine due to a significant increase in pain and shortness of breath. According to the triage notes, ";Per Enclara (the agencys pharmacy), medication was ordered, but it is not arriving today, as there was an issue with order." [sic]. According to the pain assessment section on the triage note, P-1's pain was a 5 out of 10 on a numeric pain scale (with 0 being none and 10 being the highest). The virtual team was to follow-up. The call log showed the virtual team accepted the patient at 4:50 PM. There was no evidence of CO-1 being offered or declining an in-person visit during this call. At 5:00 PM, the virtual team documented a follow-up call with P-1's wife that stated an order was confirmed with CVS Pharmacy for morphine. There was no update documented regarding the patients pain or shortness of breath status during this call. There was also no evidence of CO-1 being offered or declining an in-person visit during this call. At 5:53 PM, P-1's wife called triage again to report she went to CVS and was told they did not have an order for P-1 for morphine. She was also told they would not have any morphine in stock, even if an order was received. The patient was now completely out of morphine according to the record. P-1's wife suggested there was a Rite Aide pharmacy nearby to try. The virtual team was to follow-up again. There was no update documented regarding the patients pain or shortness of breath status during this call. There was also no evidence of CO-1 being offered or declining an in-person visit during this call. At 6:30 PM, P-1's wife called triage to report again that CVS did not have the morphine in stock and the patient was still in urgent need as his symptoms were getting worse. There was no update documented regarding the patients pain or shortness of breath status during this call. There was also no evidence of CO-1 being offered or declining an in-person visit during this call. At 6:45 PM, a follow-up triage note reported refills were attempted at CVS, Rite Aid and Walmart, however, none were able to fill the urgent order. An on-call nurse was dispatched at this time to deliver a Comfort Pack, which would include more morphine. This note was signed at 6:55 PM by the virtual team nurse. At 6:55 PM, P-1's daughter called to report the patient had taken his last breath. The dispatch nurse for the medication was canceled. During an interview on 9/18/24 at 3:30 PM, the Administrator (Staff A) was asked what the expectation is for an on-call nurse to be dispatched to assess a patient on the weekend or after hours. Staff A stated it is procedure that a nurse should be out to assess a patient within an hour of a call stating a significant change in status, including (but not limited to) an increase in pain or shortness of breath. Staff A was also asked what the procedure would be if a pharmacy was out of a medication that a patient had an urgent need for. Staff A stated that prior to ordering a medication for an urgent need, the staff must call the pharmacy to ensure its availability. Staff A stated if it is not available at the pharmacy, all on-call nurses carry additional Comfort Paks that include morphine and Ativan. Staff A stated there are always at least 4 on-call nurses per region on-duty every on-call shift. If one nurse does not have a Comfort Pak available, another nurse should be available to assist in getting the medication delivered to the patient. Also, during the interview, Staff A was asked if there was an expectation for the triage team and virtual team to fill out the section on the note regarding pain or shortness of breath during triage calls to assist in determining patient immediate needs. Staff A stated the triage team and virtual team is not expected to fill this out during triage calls. Staff A stated the on-call nurse sent to visit the patient would be responsible for that to determine the immediate needs of the patient. Regarding the events that occurred with P-1, Staff A stated the initial triage call at 4:32 PM that indicated a significant change in status and an urgent need for more pain medication should have prompted an immediate dispatch to assess the patient in person. The on-call nurse could have delivered a Comfort Pak with more morphine at that time. This also would have avoided the delay in care that resulted in the patient not getting the medication to relieve his pain at end of life. Staff A acknowledged the findings. Additionally, upon review of P-1's medication orders, it was noted there were 2 separate orders for morphine dated 7/23/24. They were both documented as ";CP – Morphine Sulfate (Concentrate) By Mouth Solution 20 MG/ML 20 mg/mL Oral 0.25 ml PRN Every 3 hours Pain/shortness of breath." [sic] Staff A was asked about the 2 separate orders for morphine. Staff A stated the nurse who does the admission evaluates if the patient needs a Comfort Pak (CP). If the patient needs a Comfort Pak, the nurse leaves a 2-medication pack that contains morphine and Ativan to get the patient started. An order is then sent to the physician to sign for a larger Comfort Pak containing 7 medications (including more morphine). Enclara (the agency's pharmacy) is contacted to fill the prescription. Staff A stated the larger Comfort Pak is delivered to the patient the next day, or within 2 days at most. Therefore, P-1 should have received it by 7/25/24 at the latest. Staff A stated there was an issue with the order for the 7-medication Comfort Pak. It was discovered the order went to an ";error box" and was never signed by the physician. As a result, this patient never received the initial medications ordered at admission. Staff A was asked if the agency follows-up with the patients to ensure the medications are received. Staff A stated they don't, as there is no way for them to track this. Staff A stated it is assumed the ";medication is sufficient" if the patient or family does not call. As a result of the events above, P-1 did not receive the needed medications on admission and during an urgent need. P-1 also did not receive a timely on-call nursing visit to assess his change in status (a significant increase in pain and shortness of breath). The agency failed to ensure nursing services were adequately and promptly provided to meet the needs of this patient at end of life. Staff A acknowledged the findings following full review of the information during an interview on 9/19/24 at 9:03 AM.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 1 (100%) live discharges reviewed where the patient was discharged due to extended prognosis, revealed the agency provided the Notice of Medicare Provider Non-Coverage Notice less than 48 hours before discharge and did not adhere to agency policy. . Document 4: Agency policy no. 0980 titled Discharges, with an updated effective date of 2/1/2020, stated in part under the subtitle Procedure... (5) "If the IDT determines that the patient no longer meets hospice eligibility requirements, discharge planning occurs as follows: (a) The patient and his or her caregivers are included in the discharge planning process and members of the IDT provide appropriate education and support as needed; (b) The RN consults with the patient's attending physician regarding the need for other health care services and obtains appropriate discharge and referral orders; (c) The RN or Social Worker arranges for these services at the request of the patient/caregiver after acquiring physician approval; (d) If the patient resides in a facility, collaboration with facility staff will occur regarding the discharge. (e) Notification of the discharge date is provided to the patient or representative and to the patient's attending physician as soon as it is determined. (f) Agency staff will assure continuity of patient care through appropriate discharge planning, communication with physicians, other health care providers, and with the receiving hospice provider, if there is one. (g) Notice of Medicare Provider Noncoverage form is delivered and explained to the patient no later than 2 days before the discharge date." Record 2: The patient with election of hospice benefit dated 3/3/2022 had a primary diagnosis of Parkinson's disease. The IDT meeting note dated 8/25/2022 documented "safe discharge planning in process," and was signed by the physician on 8/25/2022. The RN narrative note dated 08/25/2022 documented "call daughter and explained patient no longer qualifies with hospice. No other needs at this time." Notice of Medicare Non-Coverage dated 8/25/2022 and signed by daughter 8/25/2022 had an effective discharge date of 8/26/2022. There was no documentation prior to the IDT Meeting on 8/25/2022 documenting discharge planning or discussion. The last MSW visit dated 8/3/2022 documented "spoke with the facility nurse and other facility staff. Both stated patient was doing well and had no concerns. SW completed hospice agency care communication sheet on the unit. Reinforced calling hospice agency for assistance." During an interview with the Administrator on 2/2/2023, it was confirmed the IDT did provide less than 24-hour notice for discharge.

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; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; 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 a review of clinical records, interviews and observations. 3 of 4 (75%) home observations where medication reconciliations were conducted, revealed the agency's medication profiles were not accurate. Home Visit 1: The patient, with the election of hospice benefit dated 4/22/2022, had a primary diagnosis of multiple sclerosis. During the visit with the social worker on 1/31/2023, a medication reconciliation was performed comparing the agency's medication profile dated 1/31/2023 to the medication bottles in the patient's home. The medication profile documented two Restoril orders for sleep and did not match the patient's medicine bottle. The first order was written Restoril 30mg capsules, take 30mg-60mg by mouth each evening at the hour of sleep, and may be taken in conjunction with 15mg caps to titrate the dose, not to exceed a total of 60mg. Additionally, the second order was written Restoril 15mg capsules, take 30-60mg by mouth each evening at the hour of sleep, and may be taken in conjunction with 30mg caps to titrate the dose, not to exceed a total of 60mg. The Restoril bottle was in a plastic bin drawer near the patient's bed. The medicine bottle was labeled Restoril 15mg; take 1-4 capsules (15mg-60mg) by mouth at bedtime. After the visit, the findings were reviewed with the administrator on 1/31/2023. The administrator spoke with the registered nurse on 1/31/2023, who stated the patient was taking 45mg of Restoril at bedtime per the physician. The registered nurse clarified and updated the medication profile with the correct dosage order of the Restoril on 2/1/2023 to match what the patient was currently taking per the physician's order and the bottle in the home. Home Visit 2: During the visit with the registered nurse at a long-term care facility on 2/1/2023 with the patient (Record 15), a medication reconciliation was performed by comparing the hospice medication profile dated 2/1/2023, provided by the agency, to the facility medication profile dated 2/1/2023, which the facility nurse printed and provided. Several medications were not consistent, with different dosages or frequencies. For example, the facility medication profile documented Acetaminophen 500 mg by mouth every 8 hours scheduled, but the hospice medication profile did not have it scheduled, only as needed every 6 hours for pain or fever. The facility medication profile documented docusate sodium (Colace, stool softener) 100 mg by mouth two times a day, but the hospice medication profile documented the frequency as once daily. The facility medication profile documented hydrocortisone cream 2.5% topically every 12 hours, and the hospice medication profile documented frequency twice weekly. The facility medication profile documented lorazepam 0.5 mg, give two tablets (1 mg) every 4 hours as needed for anxiety, but the hospice medication profile documented the lorazepam 0.5 mg every 6 hours scheduled. The facility medication profile documented Seroquel 25 mg, given 0.5 tab (12.5 mg) by mouth every 12 hours as needed for agitation or restlessness, but the hospice medication profile documented Seroquel 25 mg by mouth every 12 hours scheduled. The facility medication profile documented triamcinolone acetonide 0.1% topically at bedtime to bilateral legs, but the hospice medication profile documented to apply to legs two times (2x) weekly. The facility medication profile documented MiraLAX 17 GM by mouth every 4 hours as needed for constipation, but the hospice facility did not have the medication documented. The hospice medication profile documented Senna 8.6 mg by mouth daily schedule, but the medication was not listed on the facility medication profile. After the visit on 2/1/2023, the findings were reviewed with the administrator, who confirmed the inaccurate agency medication profile. Home Visit 4: During the visit with the registered nurse on 2/2/2023 with the patient (Record 16), a medication reconciliation was performed, comparing the hospice medication profile with the actual medications located at the personal care home. Two medications, documented on the agency's profile, were missing at the facility, Acetaminophen 500 mg by mouth every 4 hours as needed for pain or fever, effective date 7/31/2022, and Ibuprofen 200mg, take two tablets by mouth every 6 hours as needed for pain or fever, effective date 7/31/2022. During an interview with the Administrator on 2/2/2023, it was confirmed the medications should have been discontinued or refills provided to the facility to ensure the medication profile was accurate.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 16 (6%) records reviewed revealed the agency did not update the plan of care with identified problems and interventions based on the comprehensive assessments. Record 16: The patient with the election of hospice benefit dated 5/21/2022 had a primary diagnosis of multiple myeloma and documented altered mental status. The physician certification of terminal illness (CTI) narrative dated 1/16/2023 documented the patient had "advancing dementia with occasional hallucinations." A medication profile dated 2/3/2023 documented the patient was receiving Ativan 0.5 mg by mouth every 6 hours as needed for anxiety with an effective date of 6/26/2022; Ativan 1mg/mL gel apply to wrists or behind neck every 4 hours as needed for restlessness or agitation with effective date 6/27/2022; Seroquel 25 mg by mouth daily in the morning for agitation/behaviors was ordered on 1/24/2023 and Seroquel 50 mg by mouth daily at bedtime for agitation was ordered on 1/24/2023. The current care plan problems documented as of 2/3/2023 did not include problems related to altered mental status or confusion, as identified on documented assessments and interventions. During an interview with the administrator on 2/2/2023 confirmed the care plan problem was not opened based on the mental status changes identified on the assessments during the joint record review.

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 a review of clinical records and interviews.1 of 14 (7%) records reviewed where hospice aide services were accepted, revealed a lack of specific written instruction for the aide assignment, thus leaving the aide to make decisions outside the aide's scope of practice. Record 1: The patient, with the election of hospice benefit dated 3/11/2022, had accepted hospice aide services and had a frequency order dated 7/24/2022 for three times per week (3xw). The aide care plan dated 7/21/2022 assigned two types of baths, shower and bed bath, to be completed at every visit, and did not include specific orders to direct the aide in what bath to provide during each visit. The hospice aide care plan was updated on 8/2/2022, and the assigned shower bath was discontinued, and only a bed bath type remained. During an interview with the Administrator on 1/31/2023 confirmed the hospice aide care plan should not have had two types of baths during the joint record review.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 14 (21%) records reviewed where hospice aide services were accepted, revealed the aide services were not provided in accordance with the documented plan of care. Record 2: The patient, with the election of hospice benefit dated 3/3/2022, received hospice aide services where they resided in a long-term care facility. The frequency order dated 3/13/2022 documented the hospice aide frequency twice weekly (2xW). Hospice aide visits dated 3/15/2022, 3/17/2022, and 3/18/2022 documented the patient received an extra visit. The frequency order was updated on 3/20/2022 increasing the frequency to three (3) times weekly for six (6) weeks. Record 3: The patient, with the election of hospice benefit dated 12/8/2022, and received hospice aide services. The aide frequency order dated 12/8/2022 was for one time a week (1xW). The hospice aide visit note dated 12/19/2022 documented the first aide visit received. The patient did not receive an aide visit for 12/8/2022 through 12/10/2022 and for the week of 12/11/2022 through 12/17/2022. During the week of 12/25/2022 through 12/31/2022, revealed an extra visit completed with two documented aide visits dated 12/27/2022 and 12/30/2022. Record 5: The patient, with the election of hospice benefit dated 5/27/2022, received hospice aide services. The aide frequency order dated 6/12/2022 was once weekly (1xW) for seven (7) weeks. No hospice aide visit notes were documented, and the patient did not receive aide services from 6/12/2022 through 7/11/2022. The patient received a hospice aide visit dated 7/12/2022. The hospice aide missed visit note dated 6/28/2022 documented the missed visit for 6/28/2022 by RN CM, and the hospice aide missed visit note dated 7/5/2022 documented the missed visit for 7/5/2022 by RN CM. An interview with the administrator on 2/1/2023 confirmed the aide frequency order was not met during the joint record review. During an interview with the Administrator on 1/31/2023 during the joint record review, it was confirmed the aide did not have visits for the first two weeks, and no missed visit reason documentation was present. In addition, the administrator confirmed the aide made one extra visit without a frequency order for the week of 12/25/2022. A second interview with the administrator on 2/1/2023 confirmed an extra visit was completed during the joint record review.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes any advance directives. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 16 (6%) records reviewed revealed the agency did not complete or execute the patient's advance directive per State regulation. Document 5: Agency policy no. 1000, with an effective date of 2/1/2020, titled Do Not Resuscitate-Advanced Directives, stated in part, "agency complies with all State and Federal laws regarding advanced directives-do not resuscitate orders.” Under subtitle Procedure, stated in part…(3), “If available, a copy of any advanced directive is placed in the patient's clinical record, and the patient's wishes, including his or her DNR status, are communicated to the members of the IDT to be included in care planning for the patient…(4) DNR orders are signed by the patient's physician with a copy placed in the patient's clinical record and the original retained by the patient and should be in his or her possession at all times." Record 3: The patient with the election of hospice benefit dated 12/8/2022 had a primary hospice diagnosis of Lewy body dementia. No documentation of completed DNR or advance directives was located in the medical record or repository. During an interview with the Administrator on 2/2/2023, it was confirmed the advance directive for the patient was not completed during the joint record review. There was no evidence of completed or executed advanced directives per State regulations located in the patient’s medical record.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by a review of interviews and observations. 2 of 3 (67%) inspections of medical supply rooms revealed expired items. During the inspection of the medical supply room at the first alternate delivery site (ADS) on 2/1/2023, it was revealed expired items on the left lower shelf: four (4) 8oz antimicrobial lotion soaps expired August 2022 and one (1) 8oz antibacterial soap with expiration date unreadable. Also, the agency had approximately ten (10) bear-shaped containers filled with clear liquid that were not appropriately labeled. For example, some items were marked "HS" with no expiration date. The ADS Clinical Manager stated that the bear-shaped containers were hand sanitizers that were donated during the pandemic. The manager confirmed the soaps were expired, and all items, including the bear-shaped containers, were discarded and removed from circulation. During the inspection of the medical supply room at the second alternate delivery site on 2/2/2023, it was revealed expired items on the middle shelf of fourteen (14) 8oz antimicrobial lotion soaps: eight (8) expired August 2022, five (5) expired March 2022, and one (1) expired January 2022. The ADS Clinical Manager witnessed the inspection and immediately confirmed the soaps were expired and removed from circulation. During the inspection of the medical supply room at the first alternate delivery site (ADS) on 2/1/2023, it was revealed expired items on the left lower shelf: four (4) 8oz antimicrobial lotion soaps expired August 2022 and one (1) 8oz antibacterial soap with expiration date unreadable. Also, the agency had approximately ten (10) bear-shaped containers filled with clear liquid that were not appropriately labeled. For example, some items were marked "HS" with no expiration date. The ADS Clinical Manager stated that the bear-shaped containers were hand sanitizers that were donated during the pandemic. The manager confirmed the soaps were expired, and all items, including the bear-shaped containers, were discarded and removed from circulation. During the inspection of the medical supply room at the second alternate delivery site on 2/2/2023, it was revealed expired items on the middle shelf of fourteen (14) 8oz antimicrobial lotion soaps: eight (8) expired August 2022, five (5) expired March 2022, and one (1) expired January 2022. The ADS Clinical Manager witnessed the inspection and immediately confirmed the soaps were expired and removed from circulation.