Every finding on record at Ohio Living Holdings

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 observation and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the hospice medication profile was updated when medications were added, or changes were made in existing medications. HOME VISIT 2: The patient elected the hospice benefit on 01/26/2022 with diagnoses of cerebral atherosclerosis, coronary artery disease, and atrial fibrillation. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the Chaplain (Personnel Record 2) on 04/23/2025, a medication review was completed by comparing the hospice medication profile to the facility’s medication list. The SNF medication list included Acetaminophen 325mg, take two tablets every six hours as needed for pain (effective 09/21/2022). The hospice medication profile included Acetaminophen 325 mg take 2 tablets every four hours as needed for pain and elevated temperature. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/17/2024 with diagnoses of cerebral atherosclerosis, cerebral vascular accident with right side hemiplegia, insulin dependent diabetes mellitus, and malignant neoplasm of face. The patient resided in a skilled nursing facility. During the home visit observation with the Registered Nurse (RN) (Personnel Record 3) on 04/23/2025, a medication review was completed by comparing the hospice medication profile to the facility’s medication list. The SNF medication list included Acetaminophen 160mg/5ml, give 30ml (960mg) twice daily (effective 03/31/2025), Buspirone 7.5mg twice daily (effective 03/31/2025), Hyoscyamine 0.125 mg once daily, may repeat one time in four hours if symptoms are still present (effective 01/31/2025), and MiraLAX 17 grams daily (effective 03/28/2024). The hospice medication profile included Acetaminophen 160 mg/5ml, give 20ml (640mg) twice daily (effective 01/31/2025), Buspirone 5mg three times daily (effective 12/30/2024), Hyoscyamine 0.125 mg once daily, MiraLAX 17 grams daily as needed (effective 06/17/2024). The hospice medication profile also included a Scopolamine 1mg patch (effective 01/31/2025) which was not on the facility’s medication list. The patient’s hospice medications were not reconciled with the patient’s facility medications. During an interview and review of the medication profiles on 04/24/2025, the Hospice Director stated that the medications were not being reconciled and reviewed with the facility but could not provide a reason why this had not been done.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations with wound care ordered, the agency did not ensure staff performed hand hygiene and handled soiled items in the patient's care environment as outlined in agency policy and CDC guidelines. Agency policy Wound Assessment, dated 02/24/2025, required in part, "Gather and prepare the necessary equipment and supplies. Place a fluid-impermeable pad beneath the wound to keep the patient's bed linens clean and dry." The Center for Disease Control and Prevention (CDC) guidelines for hand hygiene during wound care required in part, hand hygiene should be performed after touching a patient or patient's surroundings, which includes touching wound dressings, contaminated surfaces, or the patient's skin, and after contact with blood, body fluids, or contaminated surfaces. Home Visit 3: The patient elected the hospice benefit on 06/17/2024 with diagnoses of cerebral atherosclerosis, cerebral vascular accident with right side hemiplegia, insulin dependent diabetes mellitus, malignant neoplasm of face, and unstageable pressure sore to the left heel. The patient resided in a skilled nursing facility. During the home visit observation with the Registered Nurse (RN) (Personnel Record 3) on 04/23/2025, the RN was observed to provide wound care to the patient. The RN did not place a barrier under the patient’s leg before starting the wound care. The nurse was observed to apply gloves, then the soiled dressing was removed and placed directly on the bed sheet. The nurse then cleaned the wound with the gloves soiled from removal of the dressing and placed the gauze used to clean the wound directly on the bed sheets. The nurse did not place a fluid-impermeable pad under the patient’s leg, placed the soiled dressing and used gauze directly on the bed sheets, and did not apply clean gloves before cleaning the wound as required by agency policy and CDC guidelines. The Hospice Director, who was present for the home visit, stated that when she asked the RN about not changing the gloves after removing the dressing and placing the contaminated dressing and gauze used for cleaning on the bed sheet that the RN responded that she thought she changed her gloves and that the trash can was not close enough to put the contaminated dressing and gauze in it.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure nursing care and services were provided as required by agency policy. Agency policy Ongoing Comprehensive Hospice Assessment, dated 09/15/2023, required in part, "The nurse should assess each patient on each visit, for pain, secondary symptoms related to the terminal illness, factors that alleviate or exacerbate physical symptoms, current treatment related to the identified symptoms and the patient's response, vital signs appropriate to the patient's condition, breath sounds, skin integrity, bowel sounds, elimination (urinary and bowel), mental status, appetite/diet, nutritional status, safety/home environment, patient and family/caregiver support, progress toward hospice goals and patient needs and problems, compliance with treatments and medication regimen, the need for an alternative setting or level of care." HOME VISIT 1: During the home visit observation with the Registered Nurse (RN) (Personnel Record 1) on 04/23/2025, the nurse was observed to assess the patient. The assessment did not include an assessment of the patient’s skin integrity. The Hospice Director, who was present for the home visit observation, asked the RN why the skin assessment was not completed. The nurse replied, she is in the facility all the time and if something was going on they [facility staff] would let her know. HOME VISIT 3: During the home visit observation with the Registered Nurse (RN) (Personnel Record 3) on 04/23/2025, the nurse was observed to assess the patient. The assessment did not include an assessment of the patient’s skin integrity. The Hospice Director, who was present for the home visit observation, asked the RN why the skin assessment was not completed. The nurse replied, she had assessed the patient the day before. The Hospice Director stated during an interview on 04/23/2025 that head-to-toe assessments should have been completed for the patients.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and 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 clinical record review and interview. In 1 of 16 (6%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse prepared patient specific written care instructions for the hospice aide. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/26/2022 with diagnoses of cerebral atherosclerosis, coronary artery disease, and atrial fibrillation. Review of the clinical record for the episode of care dated 03/11/2025 to 05/09/2025 revealed the plan of care included an order for hospice aide frequency of visits twice a week and included oxygen precautions every visit. Oxygen therapy was discontinued on 04/10/2025. The aide care plan assignment included oxygen precautions; however, the aide care plan was not updated after the oxygen was discontinued. During an interview and joint record review on 04/23/2025, the Hospice Director agreed the aide care plan should have been updated when the oxygen was discontinued.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by patient record review and interview. 2 of 13 (15%) patient records reviewed revealed the patient plans of care did not include orders for all medications ordered to meet the patients' needs. Record #28818 - Documentation on nursing visit notes revealed orders for the use of antifungal powder and Vagisil were not included in the plan of care. Documentation on nursing visit notes dated 5/12/22, 5/16/22, 5/19/22, 5/23/22, 5/26/22. 6/2/22. 6/6/22, 6/9/22 and 6/16/22 stated in part, "... antifungal powder applied to under breasts." Also, documentation on the nursing visit note dated 5/5/2022 stated in part: “... Vagisil to vagina”. Documentation on the nursing visit note dated 5/12/2022 stated in part, “... anti itch cream to labia.” Record #80810 - Documentation on nursing visit notes revealed orders for the use of antifungal powder was not included in the plan of care. Documentation on nursing visit notes 4/22/22, 4/25/22, 4/29/22, 5/2/22, 5/6/22, 6/15/22, 6/17/22, and 6/20/22 described the use of antifungal powder to the patient's groin and stomach folds. During an interview with the Director of Nursing on 6/22/2022, they confirmed that orders for the use of antifungal powder and Vagisil were not included in the plan of care.