Interim Healthcare Hospice of Lima

“It is required that the written Patient Bill of Rights includes the right to: have person and property treated with respect by anyone providing services on behalf of the hospice. 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 that hospice personnel providing care treated the patient with respect. HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 09/22/2025 with a terminal diagnosis of senile degeneration of the brain. The patient resided at home. During the home visit with the Hospice Aide [Personnel Record 2] on 03/10/2026, the Hospice Aide (HA) provided a bed bath. During personal care, the HA removed the patient’s gown and briefs and did not keep the patient covered with a blanket. The Clinical Manager, who was present during the home visit, confirmed the finding, stating that the Hospice Aide did not cover the patient to provide privacy during the personal care. The Clinical Manager stated that the Hospice Aide would be reeducated to ensure that patient privacy is protected in the future.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations 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 personnel record review and interview. In 1 of 1 (100%) personnel records reviewed for a Hospice Aide (HA), the agency did not ensure that all aide tasks were observed by the Registered Nurse (RN) before the aide performed them independently. PERSONNEL RECORD 2: This Hospice Aide was hired 12/10/2025. The agency completed a performance review for the Hospice Aide on 12/13/2025. There was no documentation that the assigned tasks, including 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 normal range of motion and ambulation, adequate nutrition, were assessed prior to the HA providing care. During an interview on 03/12/2026, the Administrator stated that the correct form for the Hospice Aide observation could not be found in the personnel record.”

“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 and interview. In 2 of 18 (11%) clinical records reviewed in which Hospice Aide (HA) services were provided, the agency did not ensure that written patient care instructions for the Hospice Aide were clear and complete. CLINICAL RECORD 6: This patient elected the hospice benefit on 01/24/2026 with a terminal diagnosis of atherosclerotic heart disease of the native coronary artery without angina. The hospice plan of care ordered HA visits two times a week. The initial comprehensive assessment completed by the Skilled Nurse (SN) on 01/24/2026 documented that the patient was on oxygen at 2 liters per minute (LPM) via nasal canula (NC) as needed (PRN). The HA care plan dated 01/24/2026 did not include specific instructions for the HA regarding the patient’s need for oxygen during tasks. CLINICAL RECORD 7: This patient elected the hospice benefit on 04/16/2025 with a terminal diagnosis of malignant neoplasm of the mouth. The initial comprehensive assessment completed by the Registered Nurse (RN) on 04/16/2025 documented the patient’s percutaneous endoscopic gastrostomy (PEG) tube. The hospice plan of care dated 04/16/2025 ordered HA visits two times a week. The HA care plan dated 04/16/2025 did not include specific instructions for the HA on caring for the PEG tube during tasks. During a joint clinical record review and interview on 03/11/2026, the Clinical Manager agreed these items had not been included in the HA care plans.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 18 (11%) clinical records reviewed in which Hospice Aide (HA) services were provided, the agency did not ensure that the Hospice Aide reported changes in the patient’s needs to the Registered Nurse (RN). CLINICAL RECORD 2: This patient elected the hospice benefit on 09/22/2025 with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care ordered HA visits five (5) times a week. The HA care plan dated 09/22/2025 assigned the HA to check for signs and symptoms of COVID at each HA visit. The HA visit note dated 09/26/2025 documented that the check for report of signs and symptoms of COVID was not completed. The clinical record was reviewed, and there was no documentation that the RN was notified of this change. CLINICAL RECORD 9: This patient elected the hospice benefit on 09/25/2025 with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care ordered HA visits one (1) time a week. The HA visit note dated 03/03/2026 documented that the patient refused a bath. A review of the clinical record revealed no evidence that the RN was notified of this change in patient’s needs. During a joint clinical record review and interview on 03/11/2026, the Clinical Manager stated that, according to the agency’s policy, the HA is to report to the RN if the HA plan of care is changed. And there was no documentation in the patient’s record that this was completed.”

“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. A joint review of the 2025 QAPI Annual Evaluation report with the Volunteer Coordinator and Administrator on 03/09/2026 revealed that the volunteer utilization was 0.28% for 01/01/2025 through 12/31/2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 02/18/2026, the Administrator stated that there had recently been a change in the Volunteer Coordinator position and that a performance improvement plan had been implemented to improve the volunteer program. A joint review of the 2025 QAPI Annual Evaluation report with the Volunteer Coordinator and Administrator on 03/09/2026 revealed that the volunteer utilization was 0.28% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. PERSONNEL INTERVIEW 1: During an interview on 02/18/2026, the Administrator stated that there had been a change in the Volunteer Coordinator position recently as well implementation of a performance improvement plan to improve the volunteer program.”