Every finding on record at Western Health Resources

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. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 04/05/2025 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 07/29/2025, the hospice medication profile (printed on 07/28/2025) was compared to the SNF medication profile (printed on 07/29/2025). The hospice medication profile documented: Medihoney 80% topical gel, apply 3 times weekly (ordered 07/09/2025) and. morphine 100 mg/5 ml, 0.25 to 2 ml every hour as needed (ordered 04/29/2025). Medihoney and morphine were not documented on the SNF medication profile. The SNF medication profile documented: Fleet enema daily as needed if no results from suppository (ordered 04/25/2025). The hospice medication profile did not include documentation of the Fleet enema. Additionally, the hospice medication profile documented "hyoscyamine 0.125 mg every 4 hours as needed," and the SNF medication profile documented "hyoscyamine 0.125 mg every 8 hours as needed (ordered 04/29/2025)." Clinical Record 3/ Home Visit 3: The patient elected the hospice benefit on 06/29/2025 for a diagnosis of acute combined systolic and diastolic heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 07/29/2025, the hospice medication profile (printed on 07/28/2025) was compared to the ALF medication profile (printed on 07/29/2025). The hospice medication profile documented: Dulcolax 10 mg suppository, take daily as needed (ordered 07/03/2025); haloperidol 2mg/ml, 0.25 ml every 4 hours as needed (ordered 07/03/2025); hyoscyamine 0.125 mg tablet, take every 4 hours as needed (ordered 07/03/2025), nitroglycerin 0.4 mg, take one (1) tablet every 5 minutes as needed (ordered 07/03/2025). The ALF medication profile did not document Dulcolax, haloperidol, hyoscyamine, or nitroglycerin. Additionally, the hospice medication profile documented "pantoprazole 40 mg daily" (ordered 07/03/2025), and the ALF medication profile documented "pantoprazole 40 mg, take twice daily" (ordered 07/07/2025). Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 07/24/2025 for a diagnosis of acute myeloblastic leukemia. The patient resided in an ALF. During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 07/29/2025, the hospice medication profile (printed on 07/28/2025) was compared to the ALF medication profile (printed on 07/29/2025). The hospice medication profile documented: dorzolamide 22.3 mg-timolol 6.8 mg eye drops, administered twice daily. Dorzolamide 22.3 mg-timolol was not documented on the ALF medication profile. Additionally, the hospice medication profile documented "hyoscyamine 0.125 mg, one (1) to two (2) tablets every 4 hours as needed," and "lorazepam 0.5 mg, one (1) to four (4) tablets every four hours as needed." The ALF medication profile documented "hyoscyamine 0.125 mg, one (1) tablet every four hours as needed," and "lorazepam 0.25 mg prefilled syringe every 4 hours as needed." The medications on the hospice medication profile and the ALF medication profile were ordered on 07/28/2025. During an interview and a joint clinical record review on 07/30/2025, the Administrator and Hospice Manager confirmed the findings. The Hospice Manager stated, "The facilities struggle with our comfort kits; they cannot use ranges, and we have standing orders for ranges. We want to have the ranges available for the hospice nurses to use, but do not want the facilities to start giving the higher ranges without notifying us."

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 4 of 16 (25%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 7: The patient elected hospice care on 5/25/2025 with a diagnosis of interstitial pulmonary disease. The patient resided at home. The plan of care ordered HA services twice weekly, through 05/28/2025, then once weekly. The HA care plan(s) dated 05/25/2025 assigned the HA the relevant tasks: "apply lotion, observe skin integrity, shampoo, skin care, shower with assist." The HA care plan was updated on 05/26/2025, and the HA was assigned the relevant tasks: "apply lotion, assist to dress, observe skin integrity, shampoo, skin care, shower with assist, change linens, empty urinary drainage bag." All tasks were to be completed on every visit. The initial skilled nursing (SN) assessment dated 05/25/2025 documented: "cancer lesion erupting on right jaw covered with foam dressing." The HA care plan did not notify the HA of the wound(s), nor provide specific instructions to notify the Registered Nurse (RN) if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 8: The patient elected hospice care on 07/20/2025 with a diagnosis of malignant neoplasm of the breast. The patient resided at home. The HA care plan(s) dated 07/20/2025 and updated on 07/21/2025 and 07/23/2025 assigned the HA the relevant tasks: "apply lotion, dressing, ear care, float heels, hair care, incontinence care, nail care, observe skin integrity, peri care, catheter care, shampoo, skin care, turn and position in bed, maximum assist, bed bath, change linens-weekly, and monitor status of feet. The initial SN assessment dated 07/20/2025 documented: "blister on right buttock with foam placed loosely." The HA care plan did not notify the HA of the wound(s), nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 11: The patient elected hospice care on 06/19/2025 with diagnoses of hypertensive heart disease and chronic kidney disease (CKD). The patient resided at home. The plan of care ordered HA services twice weekly. The HA care plan dated 06/19/2025 and updated on 06/25/2025 assigned the HA the relevant tasks: "dressing, hair care, observe skin integrity, turn and position in bed, bed bath, change linens," to be completed at every visit. The initial SN assessment dated 06/19/2025 documented: "surgical incision right AKA (above knee amputation) covered with dressing." A SN assessment dated 07/21/2025 documented: "Stage II buttock, Stage III coccyx, covered with foam dressings." The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 19: The patient elected hospice care on 05/07/2025 with a diagnosis of malignant neoplasm of the upper lobe. The patient resided at home. The plan of care ordered HA services twice weekly. The HA care plan(s) dated 05/09/2025 assigned the HA the relevant tasks: "shower with assist, skin care, shaving, shampoo, peri care, oral care, observe skin integrity, nail care, hair care, dressing, assist to toilet-as needed, assist to dress, apply lotion, apply barrier cream-as needed, to be completed at every visit. The HA care plan updated on 05/11/2025 assigned the same tasks as the care plan dated 05/09/2025, but removed the "as-needed" instructions. The HA care plan updated on 05/13/2025 and 05/20/2025 changed the shower to a bed bath every visit and added change linens weekly. The initial SN assessment dated 05/12/2025 documented, "Heel, cleanse site with sterile saline, pat dry, apply barrier cream and foam dressing. wound on coccyx covered with foam dressing." The HA care plan and updated care plans did not notify the HA of the wound, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. An interview and joint clinical record review were conducted with the Administrator on 07/30/2025, in which it was agreed that the wound(s) "should have been identified on the aide care plans."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 6 (17%) clinical records reviewed revealed the aide did not follow the plan of care. Clinical Record 11: SOC: 4/4/2022, Aide plan of care dated 4/4/202 assigned shower with assist every visit. On 4/14/2022, 4/18/2022, and 4/21/2022, the aide completed a bed bath per the patient's request/preference. On 4/24/2022 RN updated the aide plan of care to bed bath. An interview with the Hospice Manager and Administrator on 10/19/2022 confirmed the finding. See below

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: Maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by a review of personnel records. 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure annual clinical competency was assessed for direct care staff. Standard Policy: Qualifications, Competency Assessment, and Evaluation Process, section E. Competency Assessment-Ongoing/Annually. Staff 2: DOH 5/1/2008, RN, No annual clinical competencies noted in personnel record for 2020, 2021, and 2022. On 10/19/2022 the Hospice Manager and Administrative Director verified the competencies were not completed per policy. Staff 6: RN, APRN, DOH: 3/10/2020. No annual competencies were noted in the personnel record for 2020 (on hire), 2021, or 2022. On 10/19/2022 the Hospice Manager and Administrative Director verified the competencies were not completed per policy. Standard Policy: Qualifications, Competency Assessment and Evaluation Process, section E. Competency Assessment-Ongoing/Annually.