Every finding on record at Patient Care Hospice LLC

Based on a review of agency policy, clinical records (CR), hospice contracts, and staff interviews, it was determined that the agency failed to review and update the medication profile to ensure that all hospice medications are available to the patient when needed for one (1) of fourteen (14) CR's reviewed (CR #10). --- Findings include: Review of the agency policy #12.008 titled ‘Monitoring Medications’ was conducted on January 7, 2026 at approximately 2:00 PM and January 12, 2026, at approximately 4:45 PM which stated, "Procedure: 1. A Comprehensive Medication Review will be completed on admit and every Interdisciplinary Group (IDG) meeting, in conjunction with all comprehensive assessments.  1. Compare medication list to actual medications patient is taking.  If the patient resides in a facility, compare medication list to the facility’s medication administration record (MAR) rather than reviewing actual medications..."  Review of CR on January 5, 2026, from approximately 3:15 PM to 4:00 PM, January 6, 2026, from approximately 12:30 PM to 2:00 PM and 5:00 PM to 9:00 PM, and January 7, 2026, from approximately 11:00 AM to 3:00 PM revealed the following:CR #10, benefit election February 10, 2025, certification period reviewed December 7, 2025, through February 4, 2026.  A home visit (HV) was conducted on January 6, 2026, at approximately 9:00 AM at the patient’s place of residence, which is a personal care home.  The patient resides in a memory care unit.  Review of the facility’s ‘Medication Review Report’ on January 6, 2026, at approximately 10:00 AM revealed the following medications were not listed on the facility ‘Medication Review Report’ compared to the hospice ‘Medicine List’: Arthritis Pain Relief (Acetaminophen) ER (extended release) 650 mg (milligram) tablet by mouth, one (1) tablet two (2) times daily for mild painBisacodyl 10 mg rectal suppository, one (1) suppository rectally daily as needed for constipationLorazepam 2 mg per ml (milliliter) oral concentrate by mouth, 0.2 ml every four (4) hours as needed for anxiety or agitationThe facility ‘Medication Review Report’ contained the following medication that was not listed on the hospice ‘Medicine List’:Lidocaine Outer 4% adhesive patch applied to the lower back topically daily for pain and remover per scheduleAn interview with the Registered Nurse (RN), EMP #10, on January 6, 2026, at approximately 10:00 AM revealed that the facility’s policy is to remove medications from the ‘Medication Review Report’ that are ordered ‘as needed’ if not administered within fourteen (14) days. A review of hospice contracts on January 5, 2026, at approximately 10:30 AM revealed no contract for services with the facility in question.  The hospice Executive Director/Area Director stated that contracts are only required for skilled nursing facilities and facilities contracted for general inpatient and respite care.  The personal care home is the patient’s place of residence, and the hospice does not require a contract because skilled care is not provided.An interview with the hospice Executive Director/Area Director on January 6, 2026, at approximately 11:00 AM confirmed the information provided by the RN.  The hospice Executive Director/Area Director stated that the facility does not dispose of the medications until they have reached the expiration date listed on the medication, but a new order must be obtained to administer the medication if needed. An interview with the Executive Director/Area Director, the Regional Quality & Assurance Manager, and the Business Office Manager on January 8, 2026, at approximately 12:30 PM confirmed the above findings.

Based on home visit observations, policy and procedure review, and an interview with the facility administrator, it was determined the hospice agency failed to ensure the Registered Nurse to perform appropriate hand hygiene during a wound care procedure for one (1) out of three (3) home visits conducted (Home visit #2/Observation #3) and failed to ensure the Registered Nurse to follow the agencys ";Home Care Bag Protocol" for two (2) out of three (3) home visits (Home Visit #2/Observation #4 and Home Visit #3/Observation #5). --- Review of policy ";Hand Hygiene" on February 1, 2023 at approximately 1:30 PM states: ";....1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitized.... c. after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings. D. if moving from a contaminated body site to a clean body site during patient care..." Review of policy ";Home Care Bag Protocol Job Aid" on February 1, 2023 at approximately 1:35 PM States: ";...#14. Never return soiled equipment to the bag. Items such as stethoscopes shall be cleaned per policy/procedure and allowed to dry prior to returning them to the bag..." Home visit #2/ Observation #3, conducted on January 31, 2023, at approximately 12:30 PM, revealed Registered Nurse #1, to remove a wound care dressing from Patient #1, then proceed to cleanse the wound without first removing gloves and performing hand hygiene. RN#1 then proceeded to apply the new dressing, then remove a second wound care dressing, then cleansing the wound area, RN#1 then removed the gloves but did not perform hand hygiene. RN#1 then proceeded to apply the new wound care dressing without first donning new gloves. After completion, RN#1 proceeded to obtain the patients pulse oximetry reading without further hand hygiene. Home visit #2/ Observation #4, conducted on January 31, 2023, at approximately 12:30 PM, revealed Registered Nurse #1, to return a blood pressure cuff, stethoscope, and thermometer after patient usage, to the home care bag, without first disinfecting. Home visit #3/ Observation #5, conducted on January 31, 2023, at approximately 1:30 PM, revealed Registered Nurse #1, to return a blood pressure cuff, stethoscope, and thermometer after patient usage, to the home care bag, without first disinfecting. An interview with the agency administrator on February 1, 2023 at approximately 2:00 PM confirmed the above findings.