Accentcare Hospice & Palliative Care of Pasco Coun

“Based on agency policy’s, observations, record reviews, and interviews, the facility failed to develop a patient-centered plan of care for unlicensed staff members related to the type of assistive devices to be utilized during transfers for 6 of 23 patients reviewed who required assistance with transfers (Patients # 2, #3, # 4, #10, # 22, # 23). Based on observations, record reviews, and interviews the facility failed to develop a patient-centered plan of care for unlicensed staff members related to the type of assistive devices to be utilized during transfers for two (#2 and #22) of three sampled residents. Findings included: On 6/16/25 at 12:45 p.m. Resident #2 was observed at home with Staff E, Chaplain. The resident used a walker to ambulate and was able to move from a standing position to a sitting position. The resident was able to converse with the staff member appropriately, with some short-term memory concerns as evidence by the continuation of asking writer and staff if we had received the resident’s self-published pamphlet containing religious scriptures.Review of Resident #2s Patient Information Report revealed the resident’s start of care was 12/10/24 and the terminal diagnoses included senile degeneration of brain not elsewhere classified.Review of Resident #2s Aide Care Plan Report dated 6/16/25 at 10:11 a.m. showed staff were to “Use Assistive Devices for Transfers” every visit. The details related to the use of an assistive device was blank and did not reveal the type of assistive device staff were to utilize while assisting the resident during a transfer.Review of Resident #2’s Home Health Aide (HHA) visit note reports dated 5/27, 6/4, 6/9, and 6/16/25 revealed staff had used assistive devices for transfers however did not reveal the type device utilized.Review of the Registered Nurse (RN) subsequent with supervisory visit note, dtated 6/12/25 revealed the resident ambulated with “assistive device”.Review of Resident #2s Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update report, dated 6/17/25 showed the reason for the meeting was as needed “prn”. Staff E documented the reason for the care plan discussion was “code status”.Review of Resident #2s recurring Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update report, dated 6/10/25, showed team members (Chaplain, Physician, RN, and Social Work) had reviewed the plan of care. Review of Resident #22s Patient Information Record revealed the start of care was 4/5/25 with a primary diagnosis of senile degeneration of brain not elsewhere classified.Review of Resident #22s Aide Care Plan Report revealed the Home Health Aide (HHA) was to visit the resident twice weekly for 13 weeks. The report showed the HHA was to ‘Use Assistive Devices For Transfers” every visit and did not reveal the type of assistive device the aide was to utilize during a transfer.Review of Resident #22s recurring Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update report, dated 6/12/25 showed the patient ambulated with walker, was agitated with care but easily redirected. The RN review showed no updates to the Aide Care Plan had occurred in the past 2 weeks.Review of Resident #22s Hospice Certification and Plan of Care for the Certification Period of 4/5/25 to 7/3/25 revealed the resident had functional limitations for bowel/bladder incontinence, endurance, and ambulation. Based on policy, observation, medical record reviews, and interviews, the facility failed to have an individualized care plan for hospice aides to follow on three patients (#3, #4 and #23) out of 23 sampled patients.Findings included:Reviewed Policy and procedure titled, “Hospice aide Plan of Care”, #2112 Protocol, revised 06/10/2024…hospice aide: reviews aide plan of care before every visit. If there are any concerns, call the assigned RN case manager, TD, or RN supervisor for clarification.hospice aide: Delivers care according to the Aide Care Plan. 1. During observation on 06/16/2025 at 12:00 PM of Staff A revealed the aide utilized a gait belt (belt that provides support and handles for caregivers to hold, allowing for safe assistance of the patient with activities such as standing, walking or transferring between surfaces.) to assist Patient #4 out of seat and pivoted patient into a wheelchair to take him to the shower. 1. Reviewed the medical record for patient #4 revealed that the patient had fall precaution, bathing – shower seated every visit. No care plan category seen on assisted devices such as a gait belt or wheelchair noted. No care plan category on transfer noted. During an interview on 06/16/2025 at 11:58 AM with Staff A inquired about the transfer of patient, and she stated, “it is on the care plan in the tablet”. surveyor asked her to see the aide care plan in which it was not on there and she disclosed that she had this patient for a long time and just knows. During an interview on 06/16/2025 at 2:22 PM with Staff K regarding assistive devices on aid care plan and she disclosed that it is on the details of the care plan next to the use of assistive devices for transfer, review of patient #4 aide care plan and she stated it should be added to the details. 2. Reviewed the medical record for patient #3 revealed that the patient has fall precautions every visit, use of assistive devices for transfer every visit and bed bath every visit and bathing shower every visit. No category seen on the mode of transfer of patient nor what assistive devices used for transfer on the aide care plan. During an interview on 06/16/2025 at 2:22 PM with Staff K inquired about patient #3 aide care plan and was informed that the nurse would put either bed bath or shower not both and that in the details they would put what assistive device. She disclosed that it is not on the aide care plan for patient #3. During an interview on 06/18/2025 at 2:41 PM with Staff C regarding Patient #3 aide plan of care and she disclosed that it looks like the patient is one person assist but the aide would not know how to transfer the patient, no assistive devices listed. 3. Review of the medical record for Patient #23 revealed that the patient has fall precautions with safe transfer listed, functional limitations with max assist bed to chair, paraplegia and the aide care plan does not have how the patient transfers from bed to chair and no list of assistive devices to use. During an interview on 06/18/2025 at 2:11 PM with Staff B regarding aide plan of care and was informed that she reviews all new admission for transfer status. Review of patient #23 aide plan of care in which she stated, “We just noticed that it doesn’t say the way that they transfer only that they are maximum assist.” Findings included:A review of the Aide Hospice visit notes dated 6/6/2025, 6/9/2025, 6/13/2025 and 6/16/2025 for patient #10 by Staff M, Hospice Aide/CNA revealed, “Service: use assistive devices for transfers, completed: Yes”.An interview was conducted on 6/17/2025 at 11:00 a.m. with the Director of Clinical Operations regarding transfers on the Aide Care Plan Reports, she stated “a note on what kind of assistive devices should be listed in the details space for each patient by the supervising registered nurse”.”

“Based on record reviews and interviews, the provider did not ensure the Hospice Aide followed the Plan of Care for 1 (#21) out of 23 patients reviewed. Findings included:A record review dated 4/9/2025 for patient #21, Aide Care Plan Report section titled, Activities of Daily Living (ADL) services revealed, “Nail Care-Clean Nails every visit”.A review of the Complaint Report dated 4/9/2025 for patient #21 revealed, “Staff F, Hospice Health Aide (HHA) cut patient fingernails too short. Blood was noted on approximately 80% fingernails during an assessment. Nurse was notified”.A Visit Note Report for patient #21 from Staff O, Registered Nurse (RN), dated 4/9/2025 revealed, “spoke to Medical Technician for facility, HHA had cut patient fingernails and left them bleeding. This nurse was unable to bandage fingers due to location”. Supervisory Functions on page 7 of 9 from same Visit Note Report for patient #21 revealed, “Is patient/family satisfied with the care delivered? Answer: No.”An interview was conducted with the Administrator on 6/17/2025 at 10:10 a.m. on review of the complaint report, she stated, “this hospice aide was re-educated on following the plan of care as written and to reach out if any questions”.An interview was conducted on 6/17/2025 at 1:00 p.m. with the Director of Clinical Operations regarding the actions of Staff F, she stated “the Aides are to only clean the fingernails, they are not to cut fingernails or toenails”.”