Interim Healthcare Hospice of Coshocton

“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 Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/17/2025 with a terminal diagnosis of senile degeneration of the brain. A review of the clinical record revealed no initial psychosocial assessment. There was no documentation that the patient/caregiver declined medical social services until 07/03/2025. There was no evidence that an initial psychosocial assessment was completed. During a joint review and interview conducted on 05/14/2026, the Administrator stated there was no documentation of social service visits provided to the patient. The Administrator stated that this patient was admitted on 04/17/2025, but there was no documentation that the patient declined SW services until an IDT note for 07/03/2025.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. 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 pain was assessed as part of the comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 03/19/2026 with a terminal diagnosis of peripheral vascular disease. The RN’s initial comprehensive assessment dated 03/19/2026 did not document that the patient was assessed for pain. During the second RN visit on 03/20/2026, the RN documented that the patient’s pain goal was 2 and that pain was not an active problem. There was no documentation that the patient was assessed for pain. The patient was not assessed for pain. The patient received acetaminophen 8-hour extended-release oral tablet 650 mg, one (1) tablet every 4 hours as needed for pain, and gabapentin enacarbil ER (extended-release) oral tablet 600 mg, one (1) tablet every 6 hours; both were started on 03/19/2026. A clinical record review revealed no documentation of an assessment of the patient’s pain including the history of the pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); or the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. During a joint review and interview on 05/14/2026, the Administrator stated that the clinical record did not include evidence that the RN’s comprehensive assessment included a complete pain assessment of the patient. The Administrator further stated that completion of comprehensive pain assessments by the RN had been identified as inconsistent through clinical record audits, and the agency was providing re-education to the RN’s to ensure that the comprehensive pain assessments were completed.”

“It is required that the documented comprehensive assessment includes 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 measures 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 3 of 4 (75%) home visits observed and clinical records reviewed, the agency did not ensure that the patient’s comprehensive assessment included a drug profile that contained the patient’s current medications to identify actual or potential drug interactions HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 03/19/2026 with a terminal diagnosis of peripheral vascular disease. During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 05/12/2026, a joint medication review was conducted comparing the hospice medication profile, dated 05/12/2026, to the patient’s medications. The patient’s spouse presented a list of medications and multiple medication bottles and reported giving the patient the medications on the list every day. The following medications were documented on the hospice medication profile but not included on the patient’s home medication list or medication bottles: indapamide tablet 2.5 mg tablet once a day in the morning and Zyprexa 5 mg tablet once a day. The bottle for cephalexin 500 mg instructed the drug to be given three (3) times a day and the hospice medication profile documented it was to be given two (2) times a day. The Clinical Manager, who was present for the visit, stated that the hospice medication profile did not match what the patient was taking in the home. HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 07/28/2025 with a terminal diagnosis of congestive heart failure. The patient resided in a skilled nursing facility (SNF). During the home visit with the Chaplain (SC) [Personnel Record 2] on 05/12/2026, a joint medication review was conducted comparing the hospice medication profile, dated 05/12/2026, to the current SNF medication administration record (MAR). The hospice medication profile documented acetaminophen 325 mg tablet, one (1) tablet every 6 hours as needed for pain. The SNF MAR documented acetaminophen 325 mg tablet, two (2) tablets every 4 hours as needed for pain. The hospice medication profile documented triamcinolone acetonide external lotion 0.1%, one (1) application external three times per day. The SNF MAR did not document triamcinolone acetonide. The Clinical Manager, who was present for the visit, stated that the hospice medication profile did not match the SNF MAR. HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 04/30/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). During the home visit with the Registered Nurse Case Manager (RNCM) [Personnel Record 3] on 05/12/2026, a joint medication review was conducted comparing the hospice medication profile, dated 05/12/2026, to the current patient’s home medications. The agency hospice medication profile documented Fluticasone-Umeclidin-Vilant inhalation aerosol powder breath activated 100-62.5-25 MCG/ACT, one (1) inhalation daily. The patient stated that they were not taking this medication. The Clinical Manager, who was present for the visit, stated that the hospice medication profile did not match what the patient was taking in the home. During an interview on 05/12/2026, the Administrator stated that an accurate review of medications the patient was currently using to identify any potential interactions had not been completed.”

“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 safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 4 (25%) home visits observed, the agency did not ensure staff followed accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 03/19/2026 with a terminal diagnosis of peripheral vascular disease. During the home visit with the Hospice Aide (Personnel Record 1) [HA] on 05/12/2026, the HA gave the patient a washcloth to clean their genital area, gave the patient another washcloth to rinse their genital area and then used the same washcloths to clean and rinse the patient’s legs and feet. During an interview, the Clinical Manager, who was present for the visit, stated the HA did not change washcloths when cleaning the patient. During an interview on 05/12/2026, the Administrator stated that the HA did not follow standard precautions and further education would be provided to the Hospice Aides to ensure that washcloths would be changed after perineal care.”

“It is required that all hospice aide services must be provided by an individual who has completed one (1) of the four (4) training and competency evaluation programs described below. 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: 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); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; [and] normal range of motion and positioning. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy “Competency and Training” stated in part: “Direct care personnel shall not independently perform tasks for which a trainer has not deemed the individual competent to perform.” In 1 of 1 (100%) personnel records reviewed for a Hospice Aide (HA), the agency did not ensure that all HA tasks were observed by the Registered Nurse (RN) before the HA performed them independently. PERSONNEL RECORD 1: This Hospice Aide was hired on 03/11/2025. A review of the personnel record revealed no evidence that an initial competency was documented at the time of hire, including observation of specific tasks before the HA performed them independently. During an interview, the Regional Manager of Clinical Operations stated that there was no documentation specifying which Hospice Aide tasks were observed at the time of hire.”

“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 clinical record review, interview, and observation. In 3 of 14 (21%) clinical records reviewed in which Hospice Aide (HA) services were provided, the agency did not ensure that the HA received written patient instructions to meet the patient’s needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 03/19/2026 with a terminal diagnosis of peripheral vascular disease. The hospice plan of care dated 03/20/2026 through 06/20/2026 ordered HA services five times a week. The RN’s initial comprehensive assessment dated 03/19/2026 documented that the patient had a Foley catheter. The HA care plan dated 03/20/2026 included an alert that the patient had a Foley catheter, but did not include instructions for Foley catheter care. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 12/18/2024 with a terminal diagnosis of cerebral atherosclerosis. The hospice plan of care dated 05/01/2026 through 06/10/2026 ordered HA services five times a week. The HA care plan dated 05/01/2026 assigned the HA the task to assist with a tub bath at each visit. During a home visit with the Medical Social Worker (MSW) [Personnel Record 4] on 05/12/2026, the patient’s apartment was observed to have a shower but no tub. The Administrator contacted the HA on 05/13/2026 and stated that the patient had been receiving tub baths while living at home, but was now receiving showers since moving to the assisted living facility (ALF). The HA care plan was not updated to instruct the HA to provide a shower. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of cerebral infarction. The updated plan of care dated 05/12/2026 ordered HA services three times a week. The HA care plans reviewed for the dates of 09/20/2024 through 05/14/2026, assigned the HA the task: “assist with shower every visit” and “complete bed bath every visit.” The HA care plan did not provide the HA with clear and complete instructions on the type of bath to be provided. During a joint review and interview on 05/14/2026, the Administrator stated that the clinical records were reviewed and that the HA care plans did not provide clear and complete instructions for the patient’s care.”

“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. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview on 05/12/2026 and a review of the agency’s cost savings report for 2025 dated 01//01/2026 with the Administrator and the Volunteer Coordinator (VC) revealed that hospice volunteer utilization for the year of 2025 (01/01/2025 through 12/31/2025) was 0.17%. The VC stated that four (4) new volunteers were being onboarded and there was a performance improvement plan to increase the volunteer hours provided to patients. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 05/12/2026 and reviewed the cost savings report for 2025 dated 01//01/2026 which revealed that the volunteer utilization for the year of 2025 was 0.17%. 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 VC stated that 4 new volunteers were being onboarded and there was a performance improvement plan to increase the volunteer hours provided to patients.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure that a copy of the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/17/2026 with a terminal diagnosis of atherosclerotic heart disease and revoked the hospice benefit on 04/07/2026. A review of the clinical record revealed that the agency did not forward the hospice discharge summary to the attending physician. During a joint review and interview on 05/14/2026, the Administrator stated that the clinical record was reviewed and the documentation stated that a discharge summary was not sent to the attending physician.”