Every finding on record at Trine Hospice Care, LLC

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. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 1: Agency Policy: Infection Control - Hand Hygiene Policy Number PC.I25 not dated, stated in part, "When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet." HOME VISIT 1: During the home visit (Clinical Record 3) on 02/04/2025 with the Hospice Aide (HA) (Personnel Record 9), the HA was observed to wash the hands with soap and water, turn off the water with wet hands, and then dry the hands with paper towels. During an interview on 05/22/2024, the Alternate Director of Patient Care Services agreed the staff did not follow the hand hygiene policy.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed the agency did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, under the direction of a physician. CLINICAL RECORD 2: The patient’s date of election was 11/26/2024. The POC/IDG [Plan of Care/Interdisciplinary Group] reviews dated 11/25/2024, 11/27/2024, 12/11/2024, 12/25/2024, 01/08/2025, and 01/22/2025 documented, "Medical Social Worker/Licensed Social Worker visit frequency initial visit for assessment and evaluation of the patient's psychosocial needs within 5 days, then once a month, 3 visits as needed and re-certification to provide psychosocial support to the patient and family." There was no documented evidence social work visits were made 1 x monthly between 12/01/2024 and 12/31/2024. A Communication Log entry for 01/31/2024 by PRR#2 documented, "Called patient to inform SW is on his way to see the patient but patient has declined and wants to reschedule the visit to another time." There were no other attempts between 01/01/2025 and 01/31/2025 to visit. During a joint record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that there was no documented evidence that social work services were provided during the times identified.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 4 (25%) clinical record review with hospice aide services revealed that the agency did not ensure that the registered nurse prepared the written patient care instructions for a hospice aide. CLINICAL RECORD 4: The POC/IDG [Plan of Care/Interdisciplinary Group] review documents dated 04/19/2024 and 04/24/2024 documented, "Hospice Aide: 2 visits per week for ADLs assistance and personal care" to start 04/19/2024. The record lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide. During a joint record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that the records lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide.

It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 1: The date of the HA [Hospice Aide] Assignment was 11/26/2024. The HA [Hospice Aide] Flow Sheets dated 12/05/2024 and 12/12/2024 documented, "Applied Nystatin on skin irritation." The HA Assignment/Plan of Care did not include "apply Nystatin on skin irritation." CLINICAL RECORD 3: The date of the HA [Hospice Aide] Assignment was 11/14/2024. The HA [Hospice Aide] Flow Sheet dated 11/29/2024 documented, "Assisted patient with her nebulizer as per request." The HA Assignment/Plan of Care did not include "assist patient with nebulizer as per request." During a joint clinical record review and interview on 02/06/2025, the Alternate Director of Patient Care Services confirmed that the hospice aide provided services that were not included in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with hospice aide services revealed that the agency did not ensure the hospice aide notified the registered nurse of care provided outside of the HA assignment. CLINICAL RECORD 1: The date of the Hospice Aide Care Plan was 11/26/2024. The HA [Hospice Aide] Flow Sheet dated 11/27/2024 documented, "MISSED VISIT Husband Ken took over the care." The HA [Hospice Aide] Flow Sheets dated 12/05/2024 and 12/12/2024 documented, "Applied Nystatin on skin irritation." The HA Assignment did not include "apply Nystatin on skin irritation." The documentation lacked evidence of a notification to the registered nurse of the application of Nystatin to the skin irritation. CLINICAL RECORD 3: The date of the HA [Hospice Aide] Assignment was 11/14/2024. The HA [Hospice Aide] Flow Sheet dated 11/29/2024 documented, "Assisted patient with her nebulizer as per request." The HA Assignment did not include "Assisted patient with her nebulizer as per request. The documentation lacked evidence of a notification to the registered nurse that the HA had assisted patient with their nebulizer. During a joint clinical record review and interview on 02/06/2025, the Alternate Director of Patient Care services confirmed that the hospice aide documentation lacked evidence of a notification to the registered nurse when care was provided that was not on the HA assignment/Plan of Care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 a review of clinical records and interviews. In 4 of 7 (57%) records reviewed the hospice did not ensure a hospice aide plan of care was documented as completed by the RN at the time of the first hospice aide visits. Clinical Record 1 was reviewed and identified the patient elected hospice care on 10/19/22 and the hospice aide visit frequency was ordered as two times a week. The hospice aide plan of care was documented on 10/28/22. There was no evidence a hospice aide plan of care was completed for the hospice aide visits conducted on 10/20/22, 10/24/22 and 10/27/22, which pre-dated the date the aide plan was documented as created. Clinical Record 2 was reviewed and identified the patient elected hospice care on 9/21/22 and the hospice aide visit frequency was ordered as two times a week. The hospice aide plan of care was documented on 10/2/22. There was no evidence a hospice aide plan of care was completed for the hospice aide visits conducted on 9/23/22, 9/27/22 and 9/30/22, which pre-dated the date the aide plan was documented as created. Clinical Record 4 was reviewed and identified the patient elected hospice care on 10/10/22 and the hospice aide visit frequency was ordered as two times a week. The hospice aide plan of care was documented on 10/16/22. There was no evidence a hospice aide plan of care was completed for the hospice aide visit conducted on 10/13/22, which pre-dated the date the aide plan was documented as created. Clinical Record 6 was reviewed and identified the patient elected hospice care on 9/8/22 and the hospice aide visit frequency was ordered as two times a week. The hospice aide plan of care was documented on 9/18/22. There was no evidence a hospice aide plan of care was present for the hospice aide visit completed on 9/15/22, which pre-dated the date the aide plan was documented as created. During interview and joint clinical review on 12/5/22, the Assistant Clinical Manager and Administrator stated "We cannot locate the missing aide plan of care, but it needs to be there; the tasks come up on the hospice aide visit notes and the tasks would not be on the aide visit notes unless they restablished the tasks on the hospice aide plan of care. We will be working with the electronic medical record company to find the missing hospice aide plans of care". No additional evidence was presented for review prior to the end of the site visit review. During interview and joint clinical review 12/5/22, the Assistant Clinical Manager and Administrator stated "We cannot locate the missing aide plan of care but it needs to be there, the tasks come up on the hospice aide visit notes and the tasks would not be on the aide visit notes unless the Restablished the tasks on the hospice aide plan of care" and "We will be working with the electronic medical record company to find the missing hospice aide plans of care".

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (29%) records reviewed the hospice did not ensure hospice aide visits were completed as ordered on the hospice plans of care. Clinical Record 5 was reviewed and identified the hospice aide visit frequency was ordered to be provided one time a week. There were no documented hospice aide visits completed during the weeks of 8/14/22 and 8/21/22. Additionally, there was no documentation to describe why the aide visits were not complete and no physician orders and/or plan of care updates for the missing hospice aide visits. Clinical Record 7 was reviewed and identified the hospice aide visit frequency was ordered to be provided two times a week. Review of the clinical record revealed three hospice aide visit notes, dated 10/10/22, 10/12/22 and 10/14/22, were present for the week of 10/10/22. There was no evidence of documented physician orders and/or plan of care updates for the one extra hospice aide visit completed during the week of 10/10/22. During interview and joint clinical review on 12/5/22, the Assistant Clinical Manager stated, "I could not locate the missing hospice aide visits, missed visit reports, and/or orders for the missing hospice aide visits. I could not locate orders and/or plan of care updates for the extra hospice aide visit". During interview and joint clinical review 12/5/22, the Assistant Clinical Manager stated "I could not locate the missing hospice aide visits, missed visit reports, and/or orders for the missing hospice aide visits" and "I could not locate orders and/or plan of care updates for the extra hospice aide visit".

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: measureable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 5 of 6 (83%) clinical records reviewed did not include documented evidence that goal statement included a description of how achievement of goals would be measured. Record #62416 was reviewed and identified a comprehensive assessment was completed on 9/15/2021. The documentation stated :“pt having lots of pain in her back with any movement d/t compression fx at L2 and L4. Pt had been taking Oxycodone for pain up until today when she can no longer swallow the pain medication. Comfort medication ordered and to be delivered to pts home today.” The plan of care dated 9/16/2021 identified a problem, “physical comfort alteration r/t metastatic cancer”, with a goal stating, “patient will achieve and maintain optimal physical comfort.” The goal statement did not include specific criteria of how achievement of the goal would be measured. Record #27756 was reviewed and identified a comprehensive assessment was completed on 10/21/2021. The documentation stated: “pt unable to give a number to her pain. She hits her hips and says ‘bad pain’.” The plan of care dated 10/21/2021 identified a problem, “physical comfort alteration r/t Alzheimer’s”, with a goal stating, “patient will achieve and maintain optimal physical comfort.” The goal statement did not include specific criteria of how achievement of the goal would be measured. Record #94379 was reviewed and identified a comprehensive assessment was completed on 10/11/2021. The documentation stated, “pt denies any pain at this time, after taking some Tylenol” and “achy, chronic, frequent pain in lower back legs worsened by ambulating, relieved by Tylenol.” The plan of care dated 10/11/2021 identified a problem, “physical comfort alteration r/t cancer diagnosis”, with a goal “patient will achieve and maintain optimal physical comfort.” The goal statement did not include specific criteria of how achievement of the goal would be measured. Record #58453 was reviewed and identified a comprehensive assessment was completed on 10/22/2021. The documentation stated the patient rated pain 0/10, with an acceptable level of 3/10, “sharp, stabbing, chronic, relieved by not moving, very painful when touched.” The plan of care dated 10/22/2021 identified a problem, “physical comfort alteration r/t progression of disease and pain in abd r/t mass”, with a goal “patient will achieve and maintain optimal physical comfort.” The goal statement did not include specific criteria of how achievement of the goal would be measured. Record #40635 was reviewed and identified a comprehensive assessment was completed on 10/29/2021. The documentation stated the patient rated as pain 4/10, with a goal of 4/10". Documentation stated, “pt took 2 Tylenol and he appeared to be comfortable prior to end of visit. Pt is using Tylenol during the day and Hydrocodone/APAP at night with some relief, but he would like more relief. RN consulted with HMD and Methadone and Dexamethasone were ordered.” The plan of care dated 10/29/2021 identified a problem, “physical comfort alteration r/t pain related to metastatic prostate cancer”, and a goal that “patient will achieve and maintain optimal physical comfort.” The goal statement did not include specific criteria of how achievement of the goal would be measured. The Director of Clinical Services was interviewed on 12/9/2021 and stated, these goals are not measurable.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. This standard was not met as evidenced by observation, document review, and interview. 3 of 3 (100%) home visit observations revealed the clinical staff did not demonstrate adherence to agency's infection prevention and control policies and procedures. Agency policy, “(agency name) Workplace Safety Plan for Occupational Exposure to COVID 19”, revised 12/9/2021, stated, in part "Screen and triage all clients, patients, residents, delivery people, visitors and other non-employees entering the setting for symptoms of COVID-19, screen other people in the home during a visit." Record #94379 During home visit observation on 12/7/2021 at 2:00 pm, hospice staff (Record #69977) entered the patient’s home without prescreening the patient's or spouse for symptoms of COVID. Record #19067 During home visit observation on 12/7/2021 at 1:00 pm, hospice staff (Record #21867) entered the patient’s home without prescreening the patient or spouse for symptoms of COVID. Record #40635 During home visit observation on 12/8/2021 at 11:00 am, hospice (Record #44845) entered the patient’s home without prescreening the patient or spouse for symptoms of COVID. The Director of Clinical Services was interviewed on 12/9/2021 and stated, the staff were screening patients for COVID-19 symptoms upon admission but not prior to daily visits.

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. 1 of 5 (20%) applicable clinical records reviewed did not include evidence of a hospice aide care plan developed at the time of the first aide visit. Record #19067 was reviewed and identified a hospice aide visit was completed on 10/22/2021. The visit narrative by the aide stated, “the patient refused his shower, but allowed me to help with a bed bath.” The hospice plan in the record was dated 10/25/2021 and there was no evidence of a hospice aide plan of care that was developed at the time of this visit. The Director of Clinical Services was interviewed on 12/9/2021 and stated, the hospice aide plan of care was dated to start on 10/25/21 but should have been dated to start on 10/22/2021.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) applicable clinical records reviewed did not include documented evidence the hospice aide followed the plan of care as assigned. Record #94379 was reviewed and identified a hospice aide plan of care dated 10/11/2021 with a visit frequency of 3 x week, assigned the aide to complete a shampoo 2 x week, and shower 2 x week. During the hospice aide visits on 10/12/21 and 10/13/21, there was no evidence the shampoo or shower were completed. The hospice aide visit narrative stated, “didn't feel like showering day, likes night.” The hospice aide plan of care was updated on 10/15/2021 to 1 x week bed bath and shampoo 2 x week. For the hospice aide visit on 10/15/21, there was no evidence the shampoo or bed bath was completed as assigned. The Director of Clinical Services was interviewed on 12/9/2021 and stated, the plan of care was not followed and “this was before the education was provided.”