Safe Haven Hospice Care Inc.

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record reviews, clinical record reviews, and interviews with the Administrator/Alternate Director of Nursing, which revealed the following: Failed to ensure the skills competency assessment for the aide was completed prior to providing unsupervised direct patient care in 1 of 1 (100%) personnel record reviewed [HSRM.9.I/L615/418.76(c)(1)]; Failed to ensure the registered nurse made an annual on-site visit to the location where a patient was receiving care in order to observe and assess each aide while he or she is performing care, in 1 of 1 (100%) of personnel record reviewed [HSRM.27.D/L632/418.76(h)(2)]; Failed to ensure the hospice aide provided services included in the plan of care [HCDT.16.I/L626/418.76(g)(2)(ii)]; and Failed to ensure the hospice aide reported 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 [HCDT.18.I/L628/418.76(g)(4)]. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that a qualified hospice aide must complete a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: Communication skills, including reading, writing, and verbally reporting clinical information to patients, caregivers, and other hospice staff, reading and recording temperature, pulse, and respiration, appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath, Sponge, tub, and shower bath, Hair shampoo (sink, tub, and bed), Nail and skin care, Oral hygiene, Toileting and elimination, Safe transfer techniques and ambulation, Normal range of motion and positioning. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed, for a hospice aide requiring an initial competency evaluation, it was revealed that the agency did not ensure that the initial aide competency evaluation was evaluated by observation of an aide’s performance with a patient or pseudo-patient. PERSONNEL RECORD 4: The hospice aide was hired on 08/07/2024. The initial skills competency form, dated 08/07/2024, listed skills such as bed bath, sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques, etc. and included columns that could be marked if the skill was ‘demonstrated’ or ‘verbalized.’ All skills on the form were marked as ‘verbal.’ The record lacked documented evidence the competency evaluation was completed by observation of an aide’s performance with a patient or pseudo-patient. Following a joint record review and interview, 08/22/2025, the Administrator/Alternate Director of Nursing confirmed that the aide told the nurse they could complete the skill but that nothing was completed by observation.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 12 (50%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the aide provided services included in the hospice aide’s plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/28/2025 with a diagnosis of Alzheimer’s Disease. The hospice aide plan of care dated 03/02/2025 listed the relevant task of shower chair every visit. The hospice aide documented on 05/16/2025, 05/21/2025, 06/27/2025, 07/28/2025, and 08/01/2025 that a bed bath was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/26/2024 with a diagnosis of Alzheimer’s Disease. The hospice aide plan of care dated 09/26/2024 listed the relevant task as shower chair every visit. The hospice aide documented on 07/23/2025, 08/012025, 08/04/2025, 08/15/2025, and 08/18/2025 that a bed bath was completed. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/13/2025 with a diagnosis of Senile Degeneration of the Brain. The hospice aide plan of care dated 05/13/2025 listed the relevant task as shower every visit. The hospice aide documented on 07/19/2025, and 07/22/2025 that a bed bath was completed. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/04/2025 with a diagnosis of Senile Degeneration of the Brain. The hospice aide plan of care dated 02/04/2025 listed the relevant task as shower every visit. The hospice aide documented on 06/27/2025, 07/21/2025 and 07/25/2025 that a bed bath was completed. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/15/2024 with a diagnosis of Senile Degeneration of the brain. The hospice aide plan of care dated 10/15/2024 listed the relevant task as shower every visit. The hospice aide documented on 03/27/2025, 04/05/2025, 04/12/2025, 04/17/2025, 05/03/2025, 05/06/2025 and 05/17/2025 that a bed bath was completed. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/03/2024 with a diagnosis of nontraumatic chronic subdural hematoma. The hospice aide plan of care dated 04/03/2024 listed the relevant task as shower every visit. The hospice aide documented on 07/23/2025, 08/01/2025, 08/04/2025, 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025 and 08/15/2025 that a bed bath was completed. During a joint record review and interview on 08/20/2025, the Administrator/Alternate Director of Nursing agreed that the hospice aides did not follow 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. 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 6 of 12 (50%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that the hospice aide reported changes to the registered nurse (RN) or that notifications to the RN were documented. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/28/2025. The hospice aide’s plan of care, dated 03/02/2025, listed the relevant task as shower chair every visit. The hospice aide documented that a bed bath was completed on 05/16/2025, 05/21/2025, 06/27/2025, and 07/28/2025. The record lacked documentation that the aide had notified the RN of the changes in the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/26/2024. The hospice aide plan of care dated 09/26/2024 listed the task of bathing as shower chair every visit. The hospice aide documented that a bed bath was completed on 7/23/2025 08/01/2025, 08/04/2025, 08/15/2025, and 08/18/2025. The record lacked documentation that the aide had notified the RN. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/13/2025. The hospice aide plan of care dated 05/13/2025 listed the relevant task as shower every visit. The hospice aide documented that a bed bath was completed on 07/19/2025 and 07/22/2025. The record lacked documentation that the aide had notified the RN. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/04/2025. The hospice aide plan of care dated 02/04/2025 listed the relevant task as shower every visit. The hospice aide documented that a bed bath was completed on 06/27/2025, 07/21/2025, and 07/25/2025. The record lacked documentation that the aide had notified the RN. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/15/2024. The hospice aide plan of care dated 10/15/2024 listed the relevant task as shower every visit. The hospice aide documented that a bed bath was completed on 03/27/2025, 04/05/2025, 04/12/2025, 04/17/2025, 05/03/2025, 05/06/2025, and 05/17/2025. The record lacked documentation that the aide had notified the RN. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/03/2024. The hospice aide plan of care dated 04/03/2024 listed the relevant task as shower every visit. The hospice aide documented that a bed bath was completed on 07/23/2025, 08/01/2025, 08/04/2025, 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025, and 08/15/2025. The record lacked documentation that the aide had notified the RN. During a joint record review and interview on 08/20/2025, the Administrator/Alternate Director of Nursing stated the aides were probably updating the RN via encrypted text but not documenting the notification in the medical record.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed, in which an annual on-site visit was required, it was revealed that the agency did not ensure that the registered nurse made an annual on-site visit to observe and assess the aide performing care. PERSONNEL RECORD 9: The hospice aide was hired on 08/15/2022. The personnel record lacked documentation of an annual on-site visit for the calendar years 2023 and 2024. The record included a completed competency form which documented that the aide verbally confirmed that they were competent to perform the skills. The record lacked documentation that an RN performed an on-site visit to observe the aide performing cares. Following a joint record review and interview, on 08/22/2025, the Administrator/Alternate Director of Nursing agreed that the hospice aides’ competencies were assessed only verbally and that they did not perform direct observation of the competencies annually.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, of patients with documented wounds, it was revealed that the agency did not ensure that the record contained clinical notes with wound descriptions. CLINICAL RECORD 3: The initial comprehensive assessment dated 06/10/2025 documented that the patient had a coccyx wound and that the wound was unstageable. Documentation in the initial comprehensive assessment and ongoing assessment clinical notes included evidence that wound care was provided as ordered and had pictures of the wounds, however lacked documentation related to wound size, degree of tissue damage, the wound bed, edges or any specific signs of improvement or deterioration. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/03/2024. A wound care order dated 04/24/2024 documented to clean the coccyx with normal saline (NS), apply Medihoney cover with foam dressing daily. On 04/29/2024, the nurse documented “sacral wound cleared.” The patient later developed another sacral/coccyx wound, and the nurse documented on 07/26/2025, “open sores on right and left buttocks and coccyx, MD notified.” The wound care orders were to “clean the coccyx wound with normal saline, pat dry, apply triad cream with Opti foam daily, as needed when soiled.” On 08/05/2025, the nurse documented the skin was clear. The record included documentation of that the wound care was provided as ordered and had pictures of the wounds, however the comprehensive assessment clinical notes lacked documentation related to wound size, degree of tissue damage, or the wound bed. During a joint record review and discussion, on 08/21/2025, the Administrator/Alternate Director of Nursing agreed that the wound documentation during the comprehensive assessments were not specific and did not include all the needed elements related a full wound assessment. The Administrator stated that there is a good wound tool within the EMR (electronic medical record) that is not being utilized properly by staff.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum each patient’s record include, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that patient’s record included complete physician orders. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/10/2025. The initial comprehensive assessment revealed that the patient had a coccyx wound at the time of admission. A wound care consult was completed, and recommendations were noted in the record. The order for the wound care, dated 08/12/2025, was written the same way as the wound consultant’s recommendation, “Applied Triad cream directly to wound bed. Covered with silicone foam dressing.” The physician order did not include the cleansing instructions, frequency of the dressing change, who would be completing the wound care, or expected duration. During a joint record review and discussion, on 08/21/2025 the Administrator/Alternate Director of Nursing agreed that the wound care order did not include the needed elements related to the care of the wound.”