Every finding on record at Hospice of the Treasure Coast Incorporated

Observed in Record Review. In 2 of 20 patient records reviewed, The organization failed to ensure that the plan of care included measurable goals related to the patient’s identified problems. For example, in HHRRHV#5, the patient was assessed as having mild dysphagia and was placed on aspiration precautions; however, the hospice plan of care did not include patient-specific, measurable goals addressing dysphagia management and prevention of aspiration. HOSRRNHV#10, despite ongoing skilled wound care interventions, the hospice plan of care did not contain patient-specific, measurable wound care goals. This finding was discussed with the Compliance Director.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to ensure that the Interdisciplinary Group (IDG) updated the Plan of care to reflect the patient’s current wound care needs. During record review of HOSRRNHV#10, the hospice nurse documented that the patient's bilateral heels became red, and order for Optifoam heel protectors was obtained. However, during the April IDG review, the goals were not revised to address the newly identified risk for skin breakdown., prevention measures, or expected outcomes. This finding was discussed and validated by the Compliance Director.

Observed in Record Review. In 10 of 23 patient records reviewed, the organization failed to ensure that the hospice plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including treatment necessary to meet the patient’s needs. For example, HOSInpatient#1, the wound care order to cleanse tumor site with normal saline, apply ABD pad daily included a PRN (as needed) intervention; however, the order did not specify the clinical indication or circumstances under which the PRN wound care should be performed. HOSInpatient#2, HOSRRHV#6, HOSRRHV#7, HOSRRHV#8, and HOSRRHV#9 the physician ordered oxygen at 2–5 liters per minute (LPM). However, the order did not include clinical parameters or indications to guide staff in determining the appropriate flow rate within the prescribed range. As a result, the order did not provide sufficient direction for consistent implementation of oxygen therapy and left the determination of the flow rate to the clinical judgment of staff without physician-defined parameters. HOSInpatient#3, the Foley catheter order did not specify the catheter size, resulting in incomplete instructions for catheter insertion and management. In record of HOSRRHV#1, an order for oxygen at 2-5 LPM PRN did not include clinical parameters indicating when oxygen should be administered or how the flow rate should be adjusted based on the severity of symptoms. HOSRRHV#4; HHRRHV#5; the physician’s order for oxygen at 2 LPM via nasal cannula PRN did not specify the indication for use e.g., shortness of breath, dyspnea, decreased oxygen saturation, or hypoxia; HOSRRHV#6: the wound care order directed application of triple antibiotic ointment; however, the order did not identify the specific medication or product to be used. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 1 of 23 patient records reviewed, the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example, HOSInpatient#3, the physician ordered skilled nursing to flush the gastrostomy tube (G-tube) every six (6) hours. However, clinical record review failed to demonstrate evidence that the G-tube flushes were performed as ordered. Documentation did not reflect the date, time, amount of flush administered, or confirmation that the intervention was completed. This finding was discussed and validated by the Hospice IPU Director.

Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to ensure that staff followed accepted standards of practice for prevention and safety when disinfecting patient care equipment. For example, in HOSRRHV#1 and HOSRRHV#5, during a home visit observation, hospice nurse cleaned a blood pressure cuff using a Sani-Cloth disinfectant wipe without wearing gloves as required by manufacturing company. This finding was discussed and validated by the Nurse Manager and Nurse Educator who were present during home visit.

Observed in Record Review. In 2 of 14 patient records with hospice aide services, the organization failed to ensure that the hospice aide care plan included patient-specific written instructions for observation, reporting, and safety measures. For example in record of HOSRRNHV#19 and HOSRRNHV#20, the patient was prescribed Aspirin, which may increase the risk of bleeding; however, the hospice aide care plan did not include instructions to observe and report signs and symptoms of bleeding gums, nosebleeds, blood in urine or stool, other abnormal bleeding. This finding was discussed and validated by the Compliance Director and Nurse Educator.

Observed in HR File Review. In 1/14 HR Files reviewed, belonging to a patient care volunteer, the Hospice Pharmacy Surveyor noted that the individual did not have documentation of an annual job specific competency assessment for 2024-2025 as required by the Hospice organization for all staff. This omission was validated with the HR Director, the Quality Director and the Education Director at the time of the survey.

Observed in Record Review. In 3 of 20 patient records reviewed, The organization failed to ensure complete authentication of entries in the clinical record. During record review HOSRRNHV#9; HOSRRNHV#14; HOSRRNHV#15; the hospice clinical staff signed and dated the paper-based Home Oxygen Fire Risk Assessment; however, professional credentials were not included with the signature. This finding was discussed and validated by the Hospice Director.

Observed in Patient Home. In 1 of 4 home visits with home oxygen conducted, the organization failed to provide patient with Information on the storage, handling, and access to medical gases. For example during a home visit of HOSRRHV#1, the hospice nurse observed an oxygen tank being stored in the garage. However, there was no evidence that the nurse provided re-education on proper oxygen storage and safety precautions in whick the patient was placed at risk for injury and a compromised safe home environment. This finding was discussed and validated by the Nurse Manager, who was present during the visit.

Observed in Building Tour. In the main electrical room there were used fluorescent light bulbs standing loose and unsecured. Used fluorescent bulbs are Universal Waste need to be stored in a sealed box and labeled as used bulbs. The observation was verified by the facilities director.

Observed in Document Review. The NFPA references with year edition were not on the 2026 and 2026 fire sprinkler inspection reports or the 2025 and 2025 fire alarm inspection reports as well as the 2025 annual fire extinguisher report. The observation was verified by the facilities director. Observed in Building Tour. In the inpatient hospice building there as trash can stored in front of the medical gas shut off near the nurse station and by the Fire Alarm Control Panel. The observation was verified by the facilities director. In the inpatient hospice building there as trash can stored in front of the medical gas shut off near the nurse station and by the Fire Alarm Control Panel. The observation was verified by the facilities director.

Observed in Emergency Management Session. During the emergency management document review, the Director of Quality and Education confirmed that the emergency operations plan did not include how the organization informs officials of any on-duty staff they are unable to contact.

Observed in Tracer Activities. In 1 of 3 bereavement records reviewed, the Bereavement Coordinator confirmed that the post-death bereavement risk assessment had not been completed within 72 hours as required by policy #804 Counseling/Bereavement.

Observed in Record Review. A review of 2 of 20 patient records, revealed the organization did not ensure the plan of care specified the care and services necessary to meet the needs identified in the comprehensive assessment. For example, during a review of the medical record(s) for HV#5, RR#2, and RR#7, it was noted that the patient’s falls risk assessment indicated the patient was at risk for falls. In addition, the patient had a history of falls. The patient’s plan of care did not include interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions.

Observed in Record Review. A review of 1 of 20 patient records, revealed that the organization did not ensure the plan of care included all required information. For example, during a review of the medical record for HV#1, it was noted that the patient experienced multiple falls during week 1 through week 8 of the 1st benefit period. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Compliance Nurse and the Director of Central Operations.

Observed in Infection Control System Tracer. During document review, the Director of Quality and Education confirmed that the hand hygiene education in the admission packet erroneously stated to wash hands for 10 seconds, which did not match the hand hygiene guidelines.

Observed in Record Review. In 2 of 15 patient records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure the instructions for patient care were implemented. For example, during a review of the medical record for HV#1, it was noted that the Hospice Aide plan of care included the following instruction: Hospice Aide visit frequency 2 times per week; Report no BM (bowel movement) in 3 days. During the first 3 weeks of the 1st benefit period the Hospice Aide did not record the date of the patient's last BM on the visit note. Example #2: During a review of the medical record for HV#2, it was noted that the Hospice Aide plan of care included the following instruction: Hospice Aide visit frequency 2 times per week; Report no BM (bowel movement) in 3 days. During the first 6 weeks of the 1st benefit period the Hospice Aide did not record the date of the patient's last BM on the visit note. This observation was reviewed with the Compliance Nurse and the Director of Central Operations.

Observed in Tracer Activities. A review of the admission packet, and documents provided to patient and family showed that the organization did not provide a copy of its written policy and procedure related to management of controlled medication.

Observed in Building Tour. During the review of the above ceiling area in the Medical Gas room, of the Hospice Inpatient Building, it was noted that the piping for hot water and automatic sprinkler system was supporting other items – gray cords were resting on this piping. This observation was reviewed with the Director of Quality and Education and the Facilities Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.