Every finding on record at Red Willow Hospice

Upon observation during home visit, 2 out 4 visits the staff did not have evidence of photo identification badges to identify visiting personnel members.

Upon patient record review, 5 of 19 (Patient #2, 3, 4, 6 and 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The medication profile at the ALF contains an order for Hydrochlorothiazide 12.5mg ½ tab daily and the hospice agency medication profile contains an order for HCTZ 12.5 mg one tab daily. Patient 3: The agency profile contains multiple medications including acetaminophen, bisacodyl, cranberry+Vit C, hyoscyamine, Metamucil, Prochlorperazine and Vit D3 and facility medication profile does not contain these medications. Patient 4: Upon home visit, agency medication profile does not contain medications patient receives at SNF including multivitamin, Albuterol Inhalers and Narcan. Patient 6: The medication profile contains multiple orders for acetaminophen orally, rectally and Norco 10-325mg prn that exceed 4 grams in 24 hours on med list with no maximum limit in 24 hours. Corrected on site with updates to order and medication profile. Patient 9: The medication profile on 11/2/25 contains multiple acetaminophen orders including 500mg 2 tabs orally every 6 hours and rectal supp 650 mg every 6 hours prn with no maximum limit in 24 hours. Corrected on site with updates to order and medication profile.

Upon patient record review, 1 of 19 (Patient # 7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 7: The POC on 9/18/25 contains medication orders for Eliquis and then changed to Plavix when Eliquis completed with no evidence of risk for bleeding on POC. Corrected on site with updates to order, medication profile and POC.

Upon patient record review, 2 of 19 (Patient # 6 and 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The POC on 11/11/25 contains multiple orders for acetaminophen orally, rectally and Norco 10-325mg prn that exceed 4 grams in 24 hours on med list with no limit to not exceed in 24 hours. Corrected on site with updates to order and medication profile. Patient 9: Updated POC on 11/11/25 contains multiple acetaminophen orders including 500mg 2 tabs orally every 6 hours and rectal supp 650 mg every 6 hours prn with no limit to not exceed 4 grams in 24 hours. Corrected on site with updates to order and medication profile.

Upon patient record review, 5 of 19 (Patient # 1, 2, 4, 7, and 13) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The updated Aide POC on 11/14/25 contains tasks as requested for clothing, foot care, nail care, oral care, peri care, shampoo and skin care. Corrected on site with updates to aide POC. Patient 2: The updated Aide POC 11/11/25 gives options of bed bath/chair bath and contains tasks as requested for clothing, foot care, nail care, oral care, peri care, shampoo and skin care. Corrected on site with updates to aide POC. Patient 4: The updated Aide POC 11/11/25 gives options of bed bath/chair bath and contains tasks as requested for clothing, foot care, nail care, oral care, peri care, shampoo and skin care and shower as requested. Corrected on site with updates to aide POC. Patient 7 : The Aide POC 9/25/25 gives options of bed bath/chair bath and contains tasks as requested for clothing, foot care, nail care, oral care, peri care, shampoo and skin care and shower as requested. Corrected on site with updates to aide POC. Patient 13: The initial Aide POC contains multiple tasks with “per patient request”. Corrected on site with updates to aide POC.

Upon observation, there was no evidence that the hospice did not bill services from a branch (multiple) location until receiving a CMS approval letter.

Upon patient client record review, 4 of 19 (Patient # 1,3,5,6, and 7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: SCP signature on IDG note 11/11/25 is signed as a PT signature. COS with signature default change in EMR. Patient 3: SCP signature on IDG note 11/11/25 is signed as a PT signature. COS with signature default change in EMR. Patient 5: SCP signature on IDG note 11/11/25 is signed as a PT signature. COS with signature default change in EMR. Patient 6: SCP signature on IDG note 11/11/25 is signed as a PT signature. COS with signature default change in EMR. Patient 7: SCP signature on IDG note 11/11/25 is signed as a PT signature. COS with signature default change in EMR.

Upon personnel record review, 1 of 12 (Personnel # 9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #9: No evidence of criminal background check for SLP.

Upon observation, there was no evidence the hospice has a CMS approval letter for all branch additions.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 The nurse placed her nursing bag and later the blood pressure cuff and stethoscope on the sofa without placing a barrier on the sofa. The nurse retrieved the equipment that was on the sofa behind her and took the patient's blood pressure and listened to the patient's chest. The soiled wipes used to clean the equipment were placed on a coffee table that was nearby without a barrier in place. At the end of the visit, the nurse discarded the soiled wipes but did not clean the area utilized on the coffee table during the visit.

Upon personnel record review, 9 of 9 applicable (Personnel #1, #2, #3, #4, #5, #6, #7, #8 and #9) did not have evidence the hospice employees and contracted employees received orientation on the hospice philosophy at time of hire.

Upon patient client record review, 1 of 8 (Patient #8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #8 During initial RN assessment the nurse documented the "wound to coccyx 4cm, edges approximated, CDI (clean, dry and intact)", and RN visit on 8/16/22 the nurse documented "6 c.m. x 3.0 c.m. x 0.5 c.m., wound draining serosanguinous fluid". The nurse documented visiting the patient on 7/19, 7/25, 8/2, 8/9, 8/23, 8/30, 9/7, 9/13, 9/20, 9/27, and 10/4/22, no evidence of wound measurements for these visits.