Interim Healthcare of Fort Wayne

“It is required that the documented comprehensive assessment include 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. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visit observations, the agency did not ensure that the drug administration record was updated, which resulted in the medication reconciliation being incomplete. HOME VISIT 1/CLINICAL RECORD 1: This patient elected the hospice benefit on 03/20/2024 with a terminal diagnosis of senile degeneration of the brain. During the home visit observation on 04/22/2026 with the Registered Nurse (Personnel Record 1), a medication review was completed by comparing the hospice drug profile to the patient’s home medications. The patient’s home medications included diclofenac sodium 1% gel apply a small amount to the affected area once a day as needed for pain, and collagen 1.7 grams with joint and mobility blend 325 mg 3 capsules a day. The hospice drug profile dated 03/01/2026-05/08/2026 did not include these medications. An interview was conducted on 04/22/2026 with the Director of Clinical Services (Personnel Record 1), and it was stated that the medications were not included in the patient’s drug profile and acknowledged that they were inadvertently omitted.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/25/2025 with a terminal diagnosis of chronic diastolic (congestive) heart failure. The registered nurse (RN)’s initial comprehensive assessment dated 04/25/2025 stated that the patient reported intense nausea after activities and eating, and the caregiver reported that the patient had nausea and vomiting multiple times per week. The drug profile dated 04/25/2025 included ondansetron 4 mg oral tablets by mouth every 8 hours as needed for nausea and vomiting. The plan of care was reviewed for the dates of 04/25/2025-10/28/2025 and included no interventions for nausea and vomiting based on problems identified in the initial comprehensive system. An interview was conducted on 04/22/2026 with the Director of Clinical Services (Personnel Record 1), and it was stated that the plan of care did not include interventions for the problem identified in the initial comprehensive assessment.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. DOCUMENT 1: Agency Policy Infection Prevention & Control in the Home Setting stated, in part: “Hand hygiene shall be performed at a minimum: before and after contact with a patient; after contact with the patient or objects in the immediate vicinity of the patient; after contact with the blood, body fluids or contaminated surfaces; immediately before applying PPE (e.g., gloves gown, facemask); immediately after removal of PPE (e.g., gloves, gown, facemask”. HOME VISIT 3 / CLINICAL RECORD 3: This patient elected the hospice benefit on 09/12/2023 with a terminal diagnosis of COPD. During a home visit conducted on 04/22/2026 to observe the Hospice Aide (Personnel Record 3) [HA], the HA met me at the door with her gloves on. We proceeded to go back to the patient’s bathroom, where the patient was sitting on the toilet. The HA cleansed the patient’s perineal area and helped the patient to her chair in the living room without sanitizing her hands. Once the patient was settled in her chair, the HA removed her gloves and donned new gloves without sanitizing her hands. She then closed up the patient’s garbage bag and asked the patient if she would like a drink. The patient stated she would like a drink of water. The HA reached into the refrigerator with the same gloves that she had touched the garbage bag without sanitizing her hands or changing her gloves. During an interview with the Director of Clinical Services (Personnel Record 1) on 04/23/2026, it was stated that the agency policy for hand hygiene was not observed during the home visit and that the hospice team would be re-educated on hand hygiene.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 12 (17%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide were clear and complete. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 03/20/2024 with a terminal diagnosis of senile degeneration of the brain. The updated plan of care dated 03/10/2026 included hospice aide visits 1X a week. The hospice aide care plan was reviewed for the dates of 03/10/2026-05/10/2026 and directed the Hospice Aide to provide a shampoo at each visit. During the home visit observation on 04/22/2026 with the Registered Nurse (Personnel Record 1), the caregiver/daughter of the patient stated that the patient received a tub bath and shampoo once a week. She stated the Hospice Aide used an inflatable basin for shampooing the hair. The hospice aide’s care plan did not include instructions to use an inflatable basin to shampoo the patient’s hair. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/25/2025 with a terminal diagnosis of chronic diastolic heart failure. The RN’s initial assessment dated 04/25/2025 was reviewed, and stated that the patient used a walker and wheelchair to ambulate. The hospice plan of care dated 04/25/2025 included orders for hospice aide visits 2X a week. The hospice aide care plan was reviewed for the dates of 05/01/2025-07/30/2025, and did not give clear instructions to use a walker and wheelchair for patient ambulation. During an interview conducted on 04/22/2026, the Director of Clinical Services (Personnel Record 1) stated, “The hospice aide care plans were not complete, and the RN staff would be re-educated to ensure that the hospice aide care plans would be completed correctly.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 04/23/2026, and the Volunteer Activity Report dated 01/01/2026 was reviewed, and revealed that the volunteer utilization for the year of 2025 was 2.05%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency recently hired a new Volunteer Coordinator who will collaborate with the corporate Volunteer Program to increase volunteer services. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 04/23/2026 and the Volunteer Activity Report dated 01/01/2026 was reviewed and revealed that the volunteer utilization for the year of 2025 was 2.05%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency recently hired a new Volunteer Coordinator who will collaborate with the corporate Volunteer Program to increase volunteer services.”