Every finding on record at Unique Hospice and Palliative Care, Inc

Observed in Record Review. In 1 of 10 records reviewed, surveyor noted that the organization failed to formulate a written plan of care based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example in RRHV#2, for the problem of pain, the goal stated Pt will experience a comfortable, peaceful, and safe stay in his/her environment of choice while on hospice over the next month, for the problem of altered skin intergrity, the goal stated The patient heel will remain free from sign and symptoms of infection. This was reviewed with the Administrator.

Observed in Record Review. In 1 of 10 records reviewed, the surveyor noted that the organization failed to provide interdisciplinary, collaborative care, treatment, or services. For example, in NHV#4, the patient/patient representative elected patient's pcp as patient's attending physician, however, there is no evidence/documentation that the attending physician was kept informed on patient's condition and updates to patient's plan of care. This was reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits, surveyor noted that the organization failed to implement activities for the prevention and control of infections and communicable diseases. In HV#1, the HHA failed to adhere to infection control and prevention protocol per the organization's policy. For example, the aide disinfected her hands and applied gloves prior to providing patient care per the policy, however, after providing care to the patient, the aide discarded soiled under-pads and removed dirty linen from the patient's bed, then the aide removed her gloves, entered her nursing bag to retrieve a new pair of gloves before disinfecting her hands, and then the aide donned the new pair of gloves without disinfecting her hands and proceeded to continue bathing the patient, increasing the risk of spreading infectious material. This was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program Review, surveyor noted that the organization failed to provide day-to-day administrative or direct patient care by volunteers in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff over the last 3 years. The organization has since implemented a performance improvement plan for the Volunteer Program that has resulted in marked improvement, demonstrating a trend towards meeting the 5% of the total patient care hours being met by volunteers. For example, in 2024, the percentage of total patient care hours by a volunteer reported by the organization rose from 1.7% at the beginning of the year to 2.5% at the end of the year, and in 2025, the percentage of total patient care hours by a volunteer reported by the organization rose from 0.7% at the beginning of the year to 3.46% currently. This was reviewed with the Administrator.

Observed in Patient Home. in 1 of 3 home visits, the surveyor failed to respect, protect, and promote the patient's rights. For example in HV#3, the aide began removing patient's clothing to provide a bed bath before closing the window blinds, adjacent to the neighboring home, in patient's room. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 10 patient records reviewed, the interdisciplinary group did not review and revise the plan of care as frequently as the patient's condition required. In HOSRR#3, the Hospice Surveyor noted in the nursing assessment that new pain medication was ordered for the patient , however, the plan of care was not revised to include any interventions to address the new pain medication. This was confirmed with the Director of Nursing.

Observed in Record Review. In 6 of 13 patient records reviewed, it was noted that the plan of care was not updated and did not note the patient's progress towards goals. For example, during records reviewed of HOSV#1-3 and RR#2, 4, and 5 the plan of care was developed at the start of care and there was no indication that any goals had been met or revised. Additionally at each recertification period the same problems, goals and interventions were identified. This was discussed with the Director Of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, it was noted by the surveyor that for HOSRR# 1, the patient had an Aspire drainage system , but it was not noted on the hospice aide care plan. The findings was verified by the Director of Nursing.