Care Dimensions, Inc.

“Based on record review and interview for seven of eight sampled Patients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7), the Agency failed to ensure that Hospice Aide services were provided per their individualized Hospice Aide Care Plan, when their assigned Certified Nurse Aide (CNA #1) did not show up, as scheduled. Findings include:Review of Agency’s Operations Policy titled Suspected Cases of Patient Abuse, Neglect, Mistreatment, or Misappropriation of Patient Property, dated August 2025, indicated the organization has a Zero-Tolerance policy for any abuse committed by an employee, volunteer, board member or third party.1. Review of Patient #1’s clinical record indicated he/she had diagnoses that include Adenocarcinoma of cecum and liver.Patient #1’s Hospice Aide Plan of Care, dated 08/15/25, indicated to maintain personal hygiene and comfort, and honor choices and wishes. Interventions included to offer showering at each visit, personal care, and light housekeeping.Review of Patient #1’s Schedule indicated CNA #1 was assigned to provide service on 08/19/25, 08/21/25, 08/26/25, and on 08/28/25, in Patient #1’s home.During a telephone interview on 10/09/25 at 1:50 P.M., Clinical Manager #1 said on 08/28/25 Patient #1’s family told her a CNA (CNA #1) had not visited Patient #1 on 08/19/25, 08/21/25, 08/26/25, or 08/28/25 and he/she needed a shower. Clinical Manager #1 said she contacted CNA #1 after her visit, who stated he may have provided services in the past two weeks, but was unable to provide services on 08/28/25 due to car issues. Clinical Manager #1 said CNA #1 documented he provided services for Patient #1 as scheduled for the past two weeks, including on 8/28/25. Clinical Manager #1 said she immediately reported the concern to her supervisor. During an interview on 09/29/25 at 12:45 P.M., the Clinical Director said upon being notified on 08/28/25 that CNA #1 had not provided Patient #1 with service that day, CNA #1’s employment through a staffing agency was terminated. The Clinical Director said through email, CNA #1 admitted to not providing any services during his two week assignment with Patient #1. The Clinical Director said she requested the assistance of Clinical Manager #2 and Clinical Manager #3 to determine if CNA #1 had also not provided services for the other Patients assigned as it was documented he had. 2. Review of Patient #2’s clinical record indicated he/she had diagnoses that included Late onset Alzheimer Disease. Patient #2’s Hospice Aide Plan of Care, dated 08/18/25, indicated to maintain personal hygiene and comfort, and to honor choices and wishes. Interventions included to provide total care with showering/bed bath, assist with dressing and undressing, shaving, foot care, perineal care, and incontinent care. Review of Patient #2’s Schedule indicated CNA #1 was assigned to provide service on 08/18/25, 08/19/25, 08/20/25, 08/21/25, 08/22/25, 08/25/25, 08/26/25, 08/27/25, and on 08/28/25. During a telephone interview on 10/03/25 at 12:20 P.M., Clinical Manager #2 said Patient #2 resided at a skilled nursing facility. Clinical Manager #2 said the nursing staff were unsure if CNA #1 had entered the Facility to provide services from 08/18/25 to 08/28/25.3. Review of Patient #3’s clinical record indicated he/she had diagnoses that included Protein Calorie malnutrition, and Moderate Alzheimer Disease. Patient #3’s Hospice Aide Plan of Care, 08/18/25, indicated indicated to maintain personal hygiene and comfort, and to honor choices and wishes. Interventions included to observe for changes in comfort and skin, assist with eating, and at each visit offer showering, fluids, assist with dressing, personal care, and mouth care. Review of Patient #4’s Schedule indicated CNA #1 was assigned to provide service on 08/18/25, 08/20/25, 08/22/25, 08/25/25, and on 08/27/25.Clinical Manager #2 said Patient #3 resided at a skilled nursing facility. Clinical Manager #2 said the nursing staff reported that they had not seen a male Hospice Aide (CNA #1) on Patient #3’s unit during those two weeks.4. Review of Patient #4’s clinical record indicated he/she had diagnoses that included Alzheimer’s Disease. Patient #4’s Hospice Aide Plan of Care, 08/18/25, indicated observe for changes in skin, eating/drinking, bowel/bladder habits, and facial expressions. Interventions also include to provide incontinent care, oral care, assist with dressing, and use of mechanical lift for transfers. Review of Patient #4’s schedule indicated CNA #1 was assigned to provide service on 08/18/25, 08/19/25, 08/20/25, 08/21/25, 08/22/25, 08/25/25, 08/26/25, and 08/27/25.Clinical Manager #2 said Patient #4 resided on a secure unit at a facility that required any individual to sign in and obtain a device to gain entry. Clinical Manager #2 said there was no record CNA #1 gained entry on any of the dates he was scheduled to provide services. 5. Review of Patient #5’s clinical record indicated he/she had diagnoses that included Alzheimer’s Disease. Patient #5’s Hospice Aide Plan of Care, dated 08/18/25 indicated to maintain personal hygiene, comfort and to honor choices. Interventions included to bath per request and observe for changes to report discomfort and signs of pain.Review of Patient #5’s schedule indicated CNA #1 was assigned to provide service on 08/26/25.During a telephone interview on 09/29/25 at 1:25 P.M., Clinical Manager #3 said Patient #5 resided at an assisted living facility and the facility was unable to confirm if CNA #1 provided service. 6. Review of Patient #6’s clinical record indicated he/she had diagnoses that included Lewy Body Dementia. Patient #6’s Hospice Aide Plan of Care, dated 08/18/25, indicated to maintain personal hygiene and comfort. Interventions included to provide bathing, perineal care and personal care. Review of Patient #6’s Schedule indicated CNA #1 was assigned to provide service on 08/18/25, 08/20/25, 08/22/25, 08/25/25, and 08/27/25.Clinical Manager #2 said Patient #3 resides in a skilled nursing facility. Clinical Manager #2 said nursing staff contacted indicated CNA #1 had not been seen at the facility on any of the dates he was scheduled to provide services.7. Review of Patient #7’s clinical record indicated he/she had diagnoses that included cognitive deficit following cerebrovascular accident.Patient #7’s Hospice Aide Plan of Care, dated 08/19/25, indicated to maintain personal hygiene and comfort, and to honor choices and wishes. Interventions included assist with eating/fluids, check for incontinence care, provide bed bath each visit, and assist with dressing, personal care, and transfers. Review of Patient #7’s Schedule indicated CNA #1 was assigned to provide services daily from 08/18/25 to 08/22/25 and from 08/25/25 to 08/28/25.Clinical Manager #2 said Patient #7 resides in a skilled nursing facility. Clinical Manager #2 said based on discussion with nursing staff at that facility, CNA #1 came one time (specific date unknown) to provide service for Patient #7 sometime between 08/17/25 to 08/23/25, but was not seen visiting Patient #7 from 08/24/25 to 08/28/25. During a telephone interview on 10/03/25 at 1:50 P.M., Certified Nurse Aide (CNA) #1 said from 08/18/25 to 08/28/25 he did not notify the Agency that he was not intending and had not provide services as scheduled for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6 and Patient #7. CNA #1 said he did not go to Patient #1’s home at all. CNA #1 said he believed he provided services (exact dates, unable to recall) once for Patient #2, Patient #3, Patient #4, and twice for Patient #7. CNA #1 said he neglected to provide services as scheduled to the Patients due to transportation and personal issues, and choose not to notify the Agency for fear of termination of employment.”

“Based on record review an interviews, for seven of seven sampled Patients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7), the Agency failed to ensure that Certified Nurse Aide (CNA #1) accurately documented services provided per the Plan of Care, when CNA #1 documented that services were provided to the patients, when they in fact had not been provided. Findings include:Review of the Agency’s Standard Documentation Policy, revised on August 2024, indicated the purpose of was to ensure accurate, legible, and complete documentation in the patients’ medical record. The Policy indicated an electronic record is maintained for every patient. The Policy indicated that Hospice Aide documentation is completed at point click care via mobile device.During a telephone interview on 10/03/25 at 1:50 P.M., Certified Nurse Aide (CNA) #1 said from 08/18/25 to 08/28/25, he did not visit to provide services as scheduled for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6 and Patient #7. CNA #1 said he believed he provided services (exact dates, unable to recall) once for Patient #2, Patient #3, Patient #4 and twice for Patient #7. CNA #1 said he documented on all seven Patient records that he provided services per the Plan of Care when he did not. During a telephone interview on 10/14/25 at 2:35 P.M. the Clinical Director said Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6 and Patient #7 were identified as being assigned to CNA #1 from 08/18/25 to 08/28/25. The Clinical Director said during Agency investigation it was determined that CNA #1 documented that he provided service visits for all seven Patient through the completion of their individualized Visit History Information- Hospice Aide Plan of Care form when he did not. The Clinical Director said although the Agency provided Patient #1’s Hospice Aide Plan of Care form completed by CNA #1, she was unable to provide the documentation for Patient #2 through Patient #7 as they were altered to reflect that services were not provided by CNA #1.”

“It is required that the written Patient Bill of Rights includes the right to: receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by document review and interview. Review of the Patient Bill of Rights revealed the agency did not ensure the document contained the patient right related to effective pain management. Document 1: The Patient Bill of Rights document, provided to patients within the admission packet, did not contain the following patient right: “the right to receive effective pain management and symptom control for conditions related to the terminal illness.” During the interview conducted on 1/29/24 the Director of Quality & Patient Experience (Personnel Record 5) confirmed that this was “missed” on the patient rights document, but the patient/families are provided education on pain and symptom management within the admission packet. Review of the Patient Bill of Rights revealed the agency did not ensure the document contained the patient right related to effective pain management.”

“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 2 of 33 (6%) records reviewed revealed the agency did not ensure that the plans of care contained specific interventions based on the patient needs identified in the comprehensive assessments. Clinical Record 11: The patient elected the hospice benefit on 11/06/2023 with a diagnosis of acute Myeloid Leukemia. The initial comprehensive assessment (11/06/2024) documented that the patient had a nasogastric tube (NG) in place and noted the patient had “increased pain.” On 01/21/2024 the registered nurse (RN) documented “mom reports patient not doing well today, increased pain” and the assessment showed the NG tube was still in place. The plan of care, effective from 11/6/2023 to current, did not include any problems, goals, or interventions related to the NG tube or alteration in comfort/pain. Clinical Record 12: The patient elected the hospice benefit on 1/22/2024 with a diagnosis of atherosclerotic heart disease and comorbidity of dysphagia. On the initial certification of terminal illness (CTI) dated 01/22/2024, the physician stated, “his hospital course was complicated by agitated delirium/toxic metabolic encephalopathy, recurrent fever, and multiple discussions surrounding nasogastric tube feedings, which patient self-discontinued with replacement, then family discontinued 01/12/2024 in favor of oral feedings despite very high aspiration risk.” The plan of care, effective from 01/22/2024 to current, did not include any problems, goals, or interventions related to dysphagia or aspiration precautions. During an interview, on 2/1/2024, the Director of Quality and Patient Experience (Personnel Record 5) agreed that the above problems were not addressed within the plan of care.”

“It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient’s plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 33 (3%) clinical records reviewed, the agency did not ensure that the patient’s pain was addressed and treated. Clinical Record 16: The patient elected the hospice benefit on 12/26/2023 with a diagnosis of Alzheimer’s disease. In the initial certification of terminal illness (CTI) dated 12/26/2023 and signed 12/27/2023, it stated, “Current x-ray right hip demonstrated impacted, displaced femoral neck fracture in varus.” In the initial RN assessment made on 12/26/2023, the RN documented under the Pain Assessment that she used the PAINAD tool to assess the patient’s pain. The RN documented: “Negative Vocalization: Score 2: Repeated troubled called out. Loud moaning; crying, Facial Expression: Score 1: Sad, frightened frowning, Body language: Score 1: Tense, distressed pacing, fidgeting. Consolability: Score 2: Unable to console, distract, or reassure. Patients score was 6/10.” According to the PAINAD scale a score of 6 signifies moderate pain. In a joint review of the clinical record with the Director of Clinical Practice and Education, it was discovered that there was no documented follow-up by the RN to address the patient’s pain. There was no evidence of documentation that the RN notified the facility staff of the patient’s pain. The following RN visit was made on 12/27/2024, 24 hours after documenting the patient’s pain. On 2/2/2024, the Director of Quality and Patient Experience (Personnel Record 5) confirmed no additional documentation regarding follow-up from the 12/26/2024 nursing visit was located.”

“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 registered nurse (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 1 of 26 (4%) clinical records reviewed, in which aide services were accepted, the agency did not ensure the RN provided specific care instructions to the hospice aide, thus leaving the aide to make decisions outside the scope of practice. Clinical Record 7: The clinical record documented the election of hospice benefit was 07/18/2023 with a diagnosis of Alzheimer’s disease, and the patient resided in a private residence. The hospice aide care plan, effective from 11/27/2023 to the present, listed the following relevant tasks: shower “as requested each visit”; Nutrition: assist with eating, offer fluids PRN (as needed) each visit; Personal care: mouth oral care PRN; shampoo with shower, PRN each visit. The aide care plan did not clarify how the aide would determine when these tasks were needed, nor did it specify any individuals who could make these decisions. The Director of Quality and Patient Experience (Personnel Record 5) reviewed the clinical record and, on 01/31/2024, said that the aide care plans should not include any PRN tasks and that this had already been fixed.”

“It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS): ensures that each location is: approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review, interview, and observation. Review of the documents for the alternate delivery site (ADS) revealed the agency did not ensure the location was approved by Medicare as an alternate delivery site. Document 4: The Administrator presented an email, dated 1/30/2024 at 1036, which stated in part, “We don’t recognize branch/satellite locations for Hospice licenses. So, if you want a second location to be included, you would have to apply for a new license with that address.” Document 7: Review of the State Hospice License document, effective from 4/1/2022 to 3/31/2024, revealed that the parent location and two inpatient facilities were on the license. An interview with the administrator (personnel record 3) conducted during the entrance conference (1/29/2024) it was stated that the agency operated the parent location, an alternate site, and two inpatient facilities. Observation 3: On 1/31/2024 tour of the ADS was conducted with the vice president (VP) who provided oversight for that location and the inpatient unit in that region. The office is located within a large nondescript building that houses multiple offices. The office locater sign, inside the building entry, identified the hospice office with the suite number. Upon approaching the suite there was a large decal signage on the door identifying the hospice. The office space contained an entry with a reception desk (unmanned at the time of the tour) and tour office which the VP reported were used if bereaved families came in for support. There was also a large open space with multiple cubicles for clinicians to come in and document (which the VP reported were seldom used since the pandemic). Approximately six offices contained nameplates on the doors and personal items within the spaces, the VP stated that one office was hers, three belonged to clinical managers and two were for clinical directors. There was a large conference room that the VP reported had been used for interdisciplinary team (IDT) meetings but those were now held virtually. There was a room set up with personal protective equipment (PPE) so that local staff could restock their supplies, if needed, all patient supplies were drop shipped directly to the patient. Per the VP the staff members that are “routinely” at that office include herself, the clinical directors, and the clinical managers all approximately 3 days per week. It was reported there were also times when an information technology (IT) staff member would be onsite for local staff to come in for issues. Personnel Record 3: On 1/30/2024 the administrator confirmed that the location listed as an alternate delivery site (ADS) was considered a satellite location by the state and thus had not been added to the state license. A review of the CMS definition for an ADS/multiple location was reviewed and per the administrator, they do have staff members report to that office but stated, “We don’t bill out of that office.” The administrator acknowledged that there are staff assigned to work in that geographic area and the patients that reside in those areas are placed on a “team” assigned to that area. During an interview on 2/2/2024, the administrator reported that after conversations with the state Department of Health, it was determined that the state did not recognize the ‘satellite’ office. The administrator did present documentation that the agency had applied to have the second location added to the Medicare form (855A) but said, “NGS said that they weren’t sure that we need to add the satellite office for Medicare.” Review of the documents for the alternate delivery site (ADS) revealed the agency did not ensure the location was approved by Medicare as an alternate delivery site.”

“It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review and interview. In 5 of 15 (33%) clinical records reviewed, in which the patient or family was administering the medications at home, the agency did not ensure the interdisciplinary plan of care identified the determination for safe medication administration in the home. Clinical Record 5: The hospice benefit was elected on 09/22/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The initial nursing assessment, dated 9/22/2023, documented the patient resided in a private home with family caregivers. The plan of care effective from admission to the current did not include documentation that the interdisciplinary group (IDG) had determined the patient/family’s ability to administer the medications safely. Clinical Record 7: The hospice benefit was elected on 07/18/2023 with a diagnosis of Alzheimer’s disease. The initial nursing assessment, dated 7/17/2023, documented the patient resided in a private home with family caregivers. The plan of care effective from admission to the current did not include documentation that the interdisciplinary group (IDG) had determined the patient/family’s ability to administer the medications safely. Clinical Record 10: The hospice benefit was elected on 11/15/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The initial nursing assessment, dated 11/15/2023, documented the patient resided in a private home with family caregivers. The plan of care effective from admission to the current did not include documentation that the interdisciplinary group (IDG) had determined the patient/family’s ability to administer the medications safely. Clinical Record 11: The hospice benefit was elected on 11/6/2023 with a diagnosis of Acute Myeloid Leukemia. The initial nursing assessment, dated 11/6/2023, documented the patient resided in a private home with family caregivers. The plan of care effective from admission to the current did not include documentation that the interdisciplinary group (IDG) had determined the patient/family’s ability to administer the medications safely. Clinical Record 14: The hospice benefit was elected on 01/8/2024 with a diagnosis of Adenocarcinoma of gastric cardia. The initial nursing assessment, dated 01/8/2024, documented the patient resided in a private home with caregivers. The plan of care effective from admission to the current did not include documentation that the interdisciplinary group (IDG) had determined the patient/family’s ability to administer the medication safely. On 2/2/2024, the Director of Quality and Patient Experience (Personnel Record 5) said that these plans of care were “missing the medication management care plan,” which was what the nurse should have used to ensure this information was documented within the plan of care.””

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed, for patients that resided in a skilled nursing facility, revealed that the agency did not ensure that the plan of care specified which provider was responsible for performing the plan of care functions that were agreed upon. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 08/25/2023 with a diagnosis of Senile Degeneration of the brain. The patient resided in a skilled nursing facility. The patient was admitted on Warfarin Sodium 1mg PO daily, varying doses depending on lab work. This same order was on the medication profile when reviewed with an agency nurse on 01/30/2024. In an interview with the skilled nursing facility staff, it was discovered that the patient was taking Warfarin 3.5mg by mouth daily. The hospice agency RN stated, “the facility staff takes care of the PT/INR.” There was no documented evidence on the hospice plan of care that the facility was performing the lab work. There was no documentation found that the agency was ensuring that the PT/INR was being performed or any documentation of the adjustments to the Warfarin. Clinical Record 20: The patient elected the hospice benefit on 1/7/2023 with a diagnosis of Malignant neoplasm of lung metastatic to the brain. The patient resided in a skilled nursing facility. On the certificate of terminal illness (CTI) dated 01/7/2024 and signed on 01/8/2024, it was stated that the “patient has an indwelling Pleurx drain for management of a malignant pleural effusion - drained every other day.” On the initial plan of care dated 01/7/2024, the hospice did not identify which provider was responsible for the care, including draining and dressing change of the indwelling Pleurx. In a joint review of the clinical record and interview (01/31/2024) with the Director of Clinical Practice and Education (Personnel Record 5), she confirmed that the designation of responsibility was not included in the plan of care. During an interview conducted on 2/2/2024, the Director of Quality and Patient Experience (Personnel Record 5) confirmed that neither of these plans of care identified which provider was responsible for the specific interventions mentioned. It was also reported that there were no additional orders or documents in which the delineation of responsibilities would have been documented.”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. In 2 of 2 (100%), observations of the inpatient facilities revealed the agency did not ensure proper food storage guidelines were followed. Observation 1: On 2/1/2024, a joint kitchen inspection was performed with the Clinical Director (personnel record 8), revealing several expired bottles of juice and dietary supplements. Observation 2: On 1/31/2024, a joint kitchen inspection with the Clinical Director (personnel record 9) revealed an open box of food. The box opening consisted of a paper flap that had been pushed in, with no way to reseal the box, leaving the contents inside open to the air. During an interview on 2/2/2024, the Director of Quality and Patient Experience confirmed that the box of dry food should have been placed in a resealable container and that there should not have been any expired food items.”