Mercy Health - Hospice Lima

“It is required that the hospice providing care in the patient’s home conduct exercises to test the emergency preparedness plan annually, including: participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years, opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The hospice did not ensure that exercises to test the emergency preparedness plan were conducted annually. A review of the agency’s Emergency Preparedness Plan and associated documentation, and an interview with the Director of Quality Outcomes on 05/26/2026, revealed no documented emergency preparedness testing for 2024. There was no documented record of an activation or conducted exercise used to evaluate the effectiveness of the agency’s Emergency Preparedness Plan. After review of the Emergency Preparedness Plan and associated documentation, as well as an interview with the Director of Quality Outcomes on 05/26/2026, it was determined that the agency did not have documentation of emergency preparedness testing for 2024. Specifically, there was no documented record of any activation or conducted exercise used to evaluate the effectiveness of the Emergency Preparedness Plan.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s initial spiritual assessment was completed within 5 days after the patient’s admission. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/22/2026. The Chaplain’s note dated 04/23/2026 documented that the initial spiritual visit would be delayed due to the Chaplain’s coverage area. The initial spiritual assessment was completed on 04/28/2026, six (6) calendar days after the patient’s election of hospice care. There was no documentation indicating the delay was based on the patient’s or family’s preference or request. A clinical record review revealed no documentation that the delay in completing the spiritual assessment was addressed through alternative arrangements, reassignment, or other measures to ensure timely assessment. During a joint clinical record review and interview on 05/29/2026, the Director of Clinical Services and the Director of Quality Outcomes confirmed that the only documented reason for the delay in completing the initial Spiritual Assessment was related to the Chaplain’s schedule and coverage area.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing the plan of care. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/22/2026 with a primary diagnosis of heart failure, unspecified. The admission assessment completed by the Registered Nurse (RN) on 04/22/2026, documented that the patient was alert and oriented to person, place, time, and situation, the patient required extended time to complete grooming and showering due to dyspnea, and required continuous oxygen at 3 liters per minute (LPM) via nasal cannula (NC). At the time of admission and during the Interdisciplinary Group (IDG) review, the patient was identified as appropriate for hospice services due to refractory congestive heart failure (CHF) with shortness of breath (SOB) at rest. The Interdisciplinary Group (IDG) Meeting on 04/22/2026 documented an initial two-week comfort goal focused on managing SOB with as-needed (PRN) medications and continuous oxygen at 3 LPM. On 05/11/2026, the RN assessment documented the patient’s continued dyspnea despite oxygen therapy. The patient remained on 3 LPM and exhibited shortness of breath during conversation, reporting feeling “winded” after minimal exertion, including walking from the bathroom and attempting to straighten the bed. Additionally, the assessment documented that the patient had slightly labored respirations and observable difficulty speaking. The IDG meeting on 05/12/2026 documented the two-week goal as maintaining the current level of dyspnea control. The POC identified comfort and dyspnea management as problem areas, with interventions including adjusting oxygen flow rate as prescribed, assessing comfort level and SOB symptoms, modifying interventions as needed, and administering medications for SOB as prescribed. The POC documented a goal for the patient “to experience relief from SOB and maintain comfort with supplemental oxygen as needed and ordered,” as well as a goal for cardiac symptom changes to be recognized within 24 hours, with appropriate interventions initiated. The documented goals for the patient’s symptom SOB management, cardiac symptoms, and dyspnea did not include measurable outcomes. During a joint clinical record review and interview on 05/29/2026, the Director of Clinical Services confirmed that the patient’s plan of care did not include goals with measurable outcomes to address the patient’s shortness of breath, dyspnea management, and cardiac symptoms. Revisions were made to the plans of care to incorporate appropriate goals with measurable outcomes before the conclusion of the site visit.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy (Procedure: IPC.11_A2) “Infection Control: Bag Technique and Standard Precautions”(revised and reviewed on 09/19/2025) stated in part, “Standard precautions are followed by all clinical team members...an approach...that assumes every person is potentially infected with a pathogen that could be transmitted; the minimum practices required...are hand hygiene including washing hands with soap and water or use of alcohol-based hand sanitizer...When to use hand gel (sanitizer): before direct patient contact and after direct patient contact...After contact with inanimate objects in the patient’s environment...” In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated, in accordance with the agency’s policy. HOME VISIT 2: During the home visit with the Chaplain [Personnel Record 9] on 05/27/2026, the Chaplain entered the Assisted Living Facility (ALF), and upon arrival at the patient’s room, the Chaplain turned the door handle and entered without performing hand hygiene. During the visit, the Chaplain prepared and administered communion to the patient, the patient’s son, and the patient’s daughter-in-law, including pouring juice into communion cups and distributing the Host by hand to all three. The Chaplain did not perform hand hygiene before or during the visit. Following the administration of communion, the patient’s paid caregiver cleaned the glass communion cups with soap and water, after which the Chaplain returned them to the container. In an interview following the visit, the Chaplain confirmed that they had not performed hand hygiene after contact with facility entry points and before preparing or administering communion. The Chaplain reported using hand sanitizer in the car before entering the building.”

“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 document review, clinical record review, and interview. Agency policy #HOS-C21 “Hospice Aide and Homemaker Services “ (reviewed and revised 12/17/2025) stated in part, “The specific activities of the HA...are written by the RN for each patient, and the HA follows the assigned activities in the delivery of care and services to the patient...” In 3 of 15 (20%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient instructions to meet the patient’s needs. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/20/2026 with a diagnosis of Parkinson’s disease. The patient resided in an assisted living facility (ALF). The plan of care (POC) for the benefit period 02/20/2026 to 05/20/2026 ordered HA visits twice weekly, which increased to three times weekly for the benefit period 05/21/2026 to 08/18/2026. On 03/12/2026, the Registered Nurse (RN) documented that the patient had incontinent of bowel and bladder and had a pressure ulcer on the coccyx measuring 3 cm x 2 cm x 0 cm, open with a small amount of serosanguineous drainage, irregular wound edges, and surrounding redness. The physician ordered cleansing of the wound, patting it dry, and applying a dressing. The wound care orders were updated on 04/24/2026 and again on 05/21/2026, with the active order directing cleansing with soap and water, patting dry, and application of a 4 x 4 foam border dressing twice weekly and as needed. The HA care plan, effective 03/16/2026 and active at the time of review, assigned the HA the tasks: bed bath, shampoo, hair care, skin care, oral care, nail care, application of a moisture barrier, and dressing the patient. The HA care plan did not provide the HA with instructions for the coccyx wound and dressing during personal care, including what to do if the dressing becomes wet, soiled, or dislodged. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/15/2025 with a primary diagnosis of heart failure and a comorbid condition of cholecystitis. The POC for the benefit period 12/15/2025 to 03/14/2026 ordered HA visits twice weekly. The POC for the benefit period 03/15/2026 to 06/12/2026 continued twice-weekly HA visits until 05/05/2026, when the visit frequency was increased to five times weekly. The admission assessment completed by the RN on 12/15/2025 documented that the patient had experienced abdominal pain resulting in an emergency room visit, where the patient was diagnosed with cholecystitis, and a drain was placed on the patient’s right side, noted to be draining dark red fluid. The active physician order at the time of review, dated 03/06/2026, ordered the caregiver or hospice nurse to empty the drain bag, monitor output, and change the Opsite clear dressing, securing the tube as needed when soiled. The HA care plan dated 03/06/2026 and active at the time of the record review assigned the HA the following tasks weekly (not at each visit): a bed bath, a shampoo, hair care, routine catheter care, shaving, oral care, nail care, and dressing the patient. The HA care plan did not provide the HA with instructions or precautions regarding the abdominal drain, or what to do if the drain or dressing becomes wet, soiled, or dislodged during personal care. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/11/2024 with a diagnosis of malignant neoplasm of the ovary. The patient resided in a nursing facility (NF). The POC for the benefit period 04/30/2026 to 06/28/2026 ordered HA visits three times weekly. The RN visit notes dated 05/06/2026 and 05/19/2026, documented the patient’s cognitive status as alert and oriented to person and place only. The HA care plan, effective 04/08/2026 and active at the time of record review, assigned the HA tasks of providing both a bed bath and a shower. The HA care plan did not include who was responsible for making that determination (e.g., RN, aide, facility staff). During a joint clinical record review and interview on 05/29/2026, the Director of Clinical Services (DCS) confirmed that the HA care plans did not include patient-specific instructions for the patients with wounds and indwelling drains. Additionally, the care plan did not provide the HA with instructions regarding the specific type of bath. Revisions to the care plans were made before the conclusion of the site visit.”

“Observed in Record Review. In 3 of 5, patient records reviewed, the nurse surveyor observed that the patient’s goals and time frames required to meet those goals were not measurable and specific. In RRNHV #1, it was noted that goals were not measurable and specific with example of patient will have optimal comfort and pain and patient demonstrated relief of uncomfortable symptoms related to constipation as evidenced by acceptable comfort level by patient. On RRNHV #3, goals were not measurable and specific with examples of balanced fluid level as evidence by reduced edema and Demonstrates relief of uncomfortable symptoms of constipation. On RRNHV #5, goals not specific with example of Patient will have knowledge of nausea with no time specific. This was reviewed and validated with the Director of Clinical Services.”

“Observed in Record Review. In 8 of 16 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and time frames required to meet those goals. In the chart for HSRRHV#1, the patient developed a pressure sore, yet the POC was not updated with a goal related to this new problem. In the chart for HSRRNHV#5, the patient developed a wound with care required. The POC was not updated with a goal. In the chart for HSRRNHV#6, the patient had a history of frequent UTIs requiring frequent hospitalizations. The patient required a Foley catheter. There was no goal on the POC related to this high risk issue. In the chart for HSRRNHV#7, there were no goals related to wound or catheter. The patient with had a history of frequent UTIs. In the chart for HSRRNHV#8, a condom catheter was initiated. The POC was not updated with a goal related to this updated treatment. In the chart for HSRRNHV#9 the target achievement date for the goal for oxygen safety knowledge was not individualized for this high risk treatment and was expected not to be met until the end of benefit period. In the chart for HSRRNHV#12, for the patient with frequent falls there was no safety goal related to the high fall risk. In the chart for HSRRNHV#14, the care plan not was not updated with a goal when the interventions for pain relief were changed. This was discussed with the Director of Clinical Services.”

“Observed in Record Review. In 11 of 16 patient records reviewed, the plan of care (POC) did not include all treatments necessary to meet the patient’s needs. In the chart for HSRRHV#1, the plan of care did not include orders for the Foley catheter/care, gall bladder drainage tube care nor oxygen which were documented in the patient comprehensive admission assessment. The nurse noted that sutures were removed from the patient’s elbow at a home visit, yet the plan of care had not been updated with an order for this treatment. In the chart for HSRRHV#2, the POC did not include the Foley catheter. In the chart for HSRRHV#3, the POC of care did not include an order for the patient’s oxygen and Foley catheter which were on the assessment. In the chart for HSRRHV#4, the nursing visit schedule was changed from daily for the dressing changes to three times per week, however the wound care order was not updated to reflect a change from daily dressings to three times weekly. In the chart for HSRRNHV#6, the patient had a Foley and oxygen however these treatments were not on the POC. In the chart for HSRRNHV#7, the POC had no orders for the wound care, nor for the suprapubic catheter care. In the chart for HSRRNHV#8, the patient had a colostomy and urostomy noted upon admission yet neither treatment were included on the POC. In the current benefit period, a RN noted that the patient had condom catheter. No order was found on the POC for this treatment. Prior to the next scheduled visit, the patient required a prn visit to address development of penis swelling with reddened areas. In the chart for HSRRNHV#9, the patient was admitted on oxygen yet the plan of care did not include an order for oxygen until approximately 2 weeks post admission. The patient was also on BIPAP which was not on the POC. In the chart for HSRRDC#16, there was no order for the oxygen on the POC. In the chart for HSRRNHV#12, for the patient with frequent falls. No patient specific interventions. In the chart for HSRRNHV#14 the POC did not include the oxygen and CPAP orders. The POC was not updated when a pain relief intervention of a cushion per patient request was added. This was discussed with the Director of Care Services.”

“Observed in Data Session. The organization had not implemented activities for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases. During the Data Session, it was noted by the surveyor that the organization had no process for surveillance of employee infections. Additionally, the patient infection surveillance data for the past 13 months indicated that the organization had no reported patient infections, despite during the patient record review, the patient in chart HSRRHV#4 had multiple infections diagnosed and treated within the past 6 months on service with the organization.”

“Observed in Record Review. In 2 of 16 patient records reviewed, staff were not supervised effectively. In the chart for HSRRNHV#7, the patient was refusing most of the personal care assigned at every aide visit. The RN documented supervision every 14 days and also that the aide was following the plan of care. There was no indication the RN was aware of the declinations of care. In the chart for HSRRNHV#9, an aide supervisory visit was documented approximately 2 months after the last aide visit was attempted and discontinued due to the patient refusing care. This was discussed with the Director of Clinical Services.”

“Observed in Tracer Activities. During a review of the volunteer program with the volunteer coordinator, the hospice pharmacy surveyor noted that the volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2025 based on the data presented, The data indicated the percentage provided averaged 3.8% for this time period. No data was available for 2024 for the surveyor to review. This omission and low percentage was validated with the volunteer coordinator and hospice management at the time of the survey.”

“Observed in Record Review. In 2 of 16 patient records reviewed, the patient record was not correct. In the chart for HSRRHV#1, the nurse noted that the patient was using Nitro for chest pain, however the medication record did not include the Nitro. In the chart for HSRRHV#4 the medication list continues to read Metronidazole 500mg tablet 2 tablets daily crush and apply to left leg wound daily. The begin date was more than 3 months prior to the survey. The RN did not apply this at the dressing change. It was confirmed with the Regional Quality Nurse that the medication profile had not been updated when the treatment was completed. This was discussed with the Director of Clinical Services.”

“Observed in Record Review. In 1 of 16 patient records reviewed, the patient record was not promptly documented. In the chart for HSRRHV#3, the patient was on daily SN visits for GIP status. There was no documentation in the record for any daily SN visits for the most recent 10 days as of the survey begin date. Additionally, the documentation of the patient’s plan of care (POC) review by the interdisciplinary group which occurred one week before the survey was not available for review in the patient chart. Organizational policy required documentation to be completed by 10am on the next business day.This was discussed with the DCS. Observed in Record Review. In 4 of 16 patient records reviewed, the documentation lacked clarity. In the chart for HSRRHV#1, in a visit note approximately 1 month post admission, a nurse documented that they removed stitches from left elbow of the patient. There was no documentation in the record of the presence of stitches in any assessment or clinical note in the patient record up until that visit. In the chart for HSRRHV#4, in a face to face visit note, the Nurse Practitioner noted that the patient had a dressing to a sacral ulcer. There was no other documentation in the record to indicate the presence of a wound, nor did the plan of care include orders for treatment of a wound. In the chart for HSRRNHV#6, in a recent visit, the RN noted patient expired prior to end of visit. However, the next day’s visit note included a full patient assessment with measurable vital signs. In the chart for HSRRNHV#10, In the chart for HSRRNHV#10, there were interventions on the plan of care related to low vision patient needs. There was no assessment data anywhere in the chart which indicated low vision was an actual problem for the patient. This was discussed with the Director of Clinical Services.”