Every finding on record at Next Care Hospice Inc.

Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 3).  This failure had the potential to result in the patient not receiving appropriate care and necessary services, which could negatively affect the patient’s well‑being. Findings: --- Review of the hospice’s P&P titled Medication Profile dated 11/2022 showed the following:-During subsequent hospice visits, the medication profile will be used as a care‑planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but is not limited to:A. Using the medication profile to evaluate the use of medications in the home setting.B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications.C. Using the medication profile as a communication tool for other clinicians involved in the patient’s care. 1.  Review of Patient 3’s clinical record was initiated on 5/4/26. The clinical record showed the SOC was 12/27/25. The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.The Medication Profile showed the patient’s medications as follows:-Jardiance (used to lower sugar with diabetes) 10 mg one tablet orally daily for diabetes.-Norco 5 mg–325 mg (opioid analgesic) one tablet orally every 4 hours as needed for moderate to severe pain.A joint home visit with RN 1 was conducted on 5/5/26 at 1100 hours, at the patient’s residence.Review of the patient’s medications with RN 1 showed the following:• Jardiance 10 mg one tablet orally daily for diabetes, was not available in the patient's home.• Norco 5 mg–325 mg one tablet orally every four hours as needed for moderate to severe pain, was also not available in the patient's home.On 5/5/26 at 1110 hours, an interview and concurrent clinical record review were conducted with RN 1 and Patient 3’s family member.  The family member stated the patient had not been taking Jardiance for approximately one month and did not believe it was needed. They further reported that they had not used Norco 5 mg–325 mg for almost one month. Instead, Patient 3 had been taking Norco 10–325 mg one tablet orally every 8 hours as needed for severe pain.On 5/5/26 at 1130 hours, an interview was conducted with RN 1.  RN 1 stated the nurse should have notified the physician of the medication changes and updated the medication profile accordingly.  RN 1 acknowledged and verified the findings.

Based on observation, interview, and record review, the hospice failed to ensure the coordination of care related to timely ordering of medication delivery and verifying the prescribed medications were available and in stock for one of the three sampled patients (Patient 3).  This failure had the potential to result in delayed medication administration and compromised continuity of care. Findings: --- Review of the agency's P&P titled "Interdisciplinary Group Coordination of Care' dated 11/22 showed personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits.  Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note.  Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Review of Patient 3’s clinical record was initiated on 5/4/26.  The clinical record showed the SOC was 12/27/26.  The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of Patient 3’s current Medication Profile showed the following:-Enemeez Rectal Enema Suspension (laxative) 283 mg one dose rectally one time for no bowel movement in three days for constipation.-hydromorphone hydrochloride (opioid analgesic) 4 mg (one ml) oral/sublingual one ml (4 mg) orally or sublingually every four hours as needed for pain or shortness of breath. A joint home visit with RN 1 was conducted on 5/5/26 at 1100 hours, at the patient’s home.  Review of the Patient 3’s medications with RN 1 showed the following medications:-Enemeez rectal enema suspension 283 mg one dose rectally one time for no bowel movement in three days for constipation. This medication was not available at the patient's home.-hydromorphone hydrochloride 4 mg (one ml) oral/sublingual one ml (4 mg) orally or sublingually every four hours as needed for pain or shortness of breath. The remaining 12 ml was expired on 5/4/26. On 5/5/26 at 1115 hours, an interview and concurrent clinical record review was conducted with RN 1.  RN 1 stated she should have ordered the medication supplies rectal enema suspension after she had used the last dose.  RN 1 stated she should have ordered the medication hydromorphone hydrochloride 4 mg before it expired.  RN 1 acknowledged and verified the findings. On 5/6/26 at 1000 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated the medication supplies should had to be ordered two days before the stock runs out.  The DPCS verified the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for one of three sampled patients (Patient 3).  This failure had the potential for not providing appropriate, consistent, and quality care to the patient. Findings: --- Review of the hospice's P&P titled Volunteer Services dated 2018, showed the Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care. Review of Patient 3’s clinical record was initiated on 5/4/26.  The clinical record showed the SOC was 12/27/25.  The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of Patient 3’s current Treatment/Medication/DME list showed Volunteer Services were offered but declined.  The Volunteer Services would continue to be offered at each recertification.Review of the Communication Log dated 12/28/25, showed the Volunteer Coordinator reported that the family was contacted on 02/27/26, to schedule a visit; however, the patient/family declined services at that time. The Volunteer Coordinator documented they would attempt to contact the patient/family again at recertification. The note further indicated the patient/family was aware the Volunteer Services remained available 24/7 and that they could contact either the Volunteer Coordinator or the office if they changed their minds. The Volunteer Coordinator planned to reassess at recertification.On 5/6/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was asked whether Volunteer Services had been reassessed and reoffered at recertification for the certification period from 3/27/26 to 6/24/26. The DPCS was unable to provide documentation and stated that it should have been documented in the Communication Log. The DPCS acknowledged and verified the findings.

Based on interview and record review, the hospice failed to ensure the individualized care plan was developed for one of three sampled patients (Patients 3).   This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patient's health condition. --- Review of the hospice’s P&P titled The Plan of Care dated 11/22 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis, no less than every fifteen (15) days.  The plan will focus on identified problems, goals, and interventions.Review of Patient 3’s clinical record was initiated on 5/4/26.  The clinical record showed the SOC was 12/27/26.  The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of the POC/IDG Reviews dated 4/15 and 4/29/26, showed an order for hydromorphone hydrochloride 4 mg/ml oral/sublingual every four hours as needed for pain or shortness of breath and an order for Norco 10 mg–325 mg 1 tablet orally every eight hours as needed for severe pain. However, the IDG/POC Reviews dated 4/15 and 4/29/26, failed to show documented evidence the IDG had developed an individualized plan of care to address Patient 3’s pain.On 5/5/26 at 1110 hours, an interview was conducted with Patient 3’s family member.  The family member stated Patient 3 had chronic knee and hip pain.On 5/6/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS was informed and verified the finding.

Observed in Tracer Activities. The organization did not protect the privacy of health information. During review of contracts it was noted that there was no documentation of a business associate agreement for the DME contract. This was confirmed by the Administrator.

Observed in Record Review. The hospice registered nurse did not complete the initial assessment of the patient within 48 hours of the election of hospice care. The hospice complies with any request by the physician or other licensed practitioner, patient, or representative to conduct the assessment in less than 48 hours. During review of record 3 it was noted that the assessment performed by the RN was completed 6 days after the election statement was signed. This was confirmed by the DPCS.

Observed in Individual Tracer. In 4 of 14 patient records reviewed, The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. During review of records 2, 4, 5, and 8 it was noted that although the patients scored at risk for falls on the fall risk assessment, there were no interventions or goals relate to fall prevention in the plan of care. This was confirmed by the DPCS.

Observed in Record Review. In 7 of 14 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 1, 2, 3, 7, 8, 9, and 10 it was noted that the visits made by disciplines were not in accord with visit orders. For example in record 2 the orders stated skilled nurse to visit 1 time per week but 5 nursing visits were made in a one week period. This was confirmed by the DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment contain all areas of hospice care related to the palliation and management of the terminal illness and related conditions to include the severity of symptoms. For example: on review of RR#9 the patient had a foley catheter yet the nursing documentation lacks a comprehensive assessment and reassessment of the urinary system to include assessing the foley catheter and elements related such as patency, urine character, clarity, and odor. RR#8 also noted the presence of a foley but lacked documentation of a comprehensive assessment of the urinary system and the presence of the foley. These observations were reviewed with the Administrator Designee and the CEO.

Observed in Record Review. In 8 of 10 patient records reviewed, the update to the comprehensive assessment failed to include information on the patient's progress toward desired outcomes and goals. Throughout the records reviewed, there was a lack of documentation of progress to goals and outcomes as the care plans remained the same without updates based on the comprehensive assessment from IDG to IDG. Further, in review of RR#4 the target dates for goals were past due as all goals target dates were noted as December 2022. In RR#6 the goals target dates were past due set for October 2022. Most care plans goals and interventions were established on admission and remained unchanged throughout care. These observations were reviewed with the Administrator Designee and the CEO.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the individualized plan of care goals were specific, measurable, attainable, realistic, and time bound. Throughout all active records reviewed there were goals noted to not be measurable, and they lacked being time bound. For example: In HV#1 there were goals such as maintain optimal mobility and independence. minimize complications due to impaired mobility. For spiritual care the goals were provide prayer, meditation, and scripture reading, and Facilitate relaxation response. In RR#5 example goal was able to participate in activities of daily living (ambulation, feeding, hygiene). In RR#8 examples of goals were optimal blood sugar management for patient comfort and optimal bowel elimination and comfort for client. Similar examples of goals that were not measurable and time bound could be noted throughout all records reviewed. Target dates for all goals were noted to be set for the end of the first benefit period after admission. These observations were reviewed with the Administrator Designee and the CEO.

Observed in Record Review. In 4 of 10 patient records reviewed, for active records, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HV#1 and HV#2 the patient was noted in documentation to have wounds, yet the issues with skin integrity was not reflected in the care plans. HV#1 also had recent documentation of starting antibiotics and prednisone yet this was not reflected in the care plan. In RR#6 the documentation noted labs performed related to dizziness/lightheaded yet this was not noted in the care plan. In RR#8 the IDG documentation noted a foley had been inserted, but the care plan did not reflect the changes. Further in RR#8 the patient was receiving spiritual care services but no spiritual care plan was open. These observations were reviewed with the Administrator Designee, and CEO.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HV#2 the patient had a nephrostomy tube yet the plan of care did not include physicians orders for the care of the tube and site. In review of RR#5 the patient was diabetic and the plan of care had an intervention that stated follow orders as specified, yet there were no physicians orders for blood glucose monitoring. In reviewing RR#8 the patient was noted to had a foley catheter per the comprehensive assessment yet there were no physicians orders for the catheter. These observations were reviewed with the Administrator Designee and CEO.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization did not ensure that care and services were provided in accordance with the plan of care. For example: on review of RR#4 and RR#6, the plan of care order for the frequency of the MSW was noted to be one time and PRN, however the MSW was seeing the patient monthly. Spiritual Care also had an order for one time and PRN yet was seeing the patient every recert. Similar issues with the Spiritual Care frequency can be seen in RR7, RR10, and HV1. These observations were reviewed with the Administrator Designee and CEO.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the bag technique policy it had established was implemented. For example: during home observation of the hospice aide at HV#1, the aide was noted to place the nursing bag on the patient's bed, in violation of policy established policy, and removed the equipment for vital signs from the bag and placed directly on the patient's bed. Further, the aide disinfected the equipment after use with a disinfecting wipe from the patient's home and immediately placed back in the bag without allowing for dry time as recommended by the manufacturer. This observation was reviewed with the Administrator Designee.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aide, the hospice failed to ensure the hospice aide had competency assessment of the required subject areas documented as part of orientation. For example: on review of HR#3 for the hospice aide there was no documentation of initial competency that addressed all required subjects noted in the HR file. This observation was reviewed with the Leadership team. Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the hospice failed to ensure the aide was competent to perform their responsibilities prior to providing patient care. On review of HR#3 for the hospice aide there was no documentation that the aide's competency was evaluated by observation with a patient or pseudo-patient as required. On discussion with the Leadership, they noted the feel the Aide was evaluated for competency during orientation however they were not able to produce this documentation on survey.

Observed in Record Review. In 8 of 8 patient records reviewed, that were receiving hospice aide services, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. For example: on review of all records were the patient was receiving aide services, the aide was assigned to obtain vital signs each visit, however there were no parameters noted to inform the aide a which point to report findings to the RN. This observation was reviewed with the Administrator Designee, and CEO.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to ensure an initial orientation for each employee that addresses the employee's specific job duties. For example: on review of HR#3 for the hospice aide, there was no documentation of an orientation provided that addressed the employees specific job duties, nor infection control and prevention. On discussion, Leadership noted that the HA completed orientation but because of internal issues they were unable to provide documentation at time of survey.

Observed in HR File Review. In 3 of 8 HR files reviewed, the organization failed to ensure documentation of assessment of the skills and competence of all individuals furnishing care as part of orientation. On review of HR#1 (RN), HR#6 (MSW/VC), and HR#7 (DPCS) there was no documentation of initial competency completed as part of the hospice orientation process. This observation was reviewed with the Leadership team.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the hospice plan of care identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon. For example: on review of HV#2 the patient documentation noted wounds, and nephrostomy tube yet on review there was no evidence of collaboration with facility staff or delegation of duties assigned throughout the clinical documentation or the plan of care. RR#5 also resided in a SNF yet no evidence of collaboration with facility staff or delegation of duties assigned was noted in the plan of care. This observation was reviewed with the Administrator Designee and the CEO.

Observed in Infection Control Tracer. As noted by the Hospice Surveyor and confirmed by the Administrator, the organization had not implemented the infection prevention and control activities it has planned. At the Home Visit, the nurse had not sanitized between glove changes during wound care as required by Organization Policy. The nurse did not sanitize her hands prior to putting equipment back into nursing bag as per Organization Policy. The Nurse did not change gloves prior to cleaning her equipment. She did not change gloves between assessing the patient and cleaning the supplies as per Organization Policy.