Interim Healthcare Hospice of Dayton

“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 2 of 14 (14%) clinical records reviewed, the agency did not ensure the patient’s symptom management goal included an expected timeframe for achievement. CLINICAL RECORD 6: This patient elected the hospice benefit on 07/27/2026 with a terminal diagnosis of bacterial arthritis. The RN comprehensive assessment dated 07/27/2026 documented that the patient was experiencing pain. The RN visit note dated 07/28/2026 included documentation of new orders for a Butrans Patch and oxycodone/acetaminophen 5- 325 mg every 4 hours. The hospice plan of care (POC) dated 07/27/2026-10/24/2026 identified a pain management goal of 4 or less. The POC did not identify an expected timeframe to achieve the pain management goal. CLINICAL RECORD 8: This patient elected the hospice benefit on 05/11/2026 with a terminal diagnosis of primary central nervous system lymphoma. The initial RN comprehensive assessment dated 05/11/2026 documented that the patient rated their pain as 4 (ESAS-Edmonton Symptom Assessment System) with a pain target of 3. The assessment also documented a depression score of 10 and an anxiety score of 10. The patient was prescribed acetaminophen extra strength 500 mg, 2 tablets every 8 hours as needed for pain, lorazepam 0.5 mg, one (1 ) tablet every 4 hours as needed for anxiety, and venlafaxine ER oral capsule 150 mg daily. The hospice plan of care (POC) for 05/11/2026-08/09/2026 identified a goal for the patient to effectively manage medications to maintain symptom control; however, the goal did not include an expected timeframe for achievement. During a joint clinical record review and interview on 08/04/2026, the Director of Regulatory Compliance and Quality (DRCQ) stated that the lack of target dates prevented measurable outcomes from being established or evaluated.”

“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 clinical record review, document review, interview, and observation. Agency policy #6.0 “Infection Prevention & Control in the Home Setting Hand Hygiene” stated, in part; “Hand hygiene shall be performed at a minimum... Immediately before applying PPE (e.g., gloves, gown, facemask)..Immediately after removal of PPE (e.g., gloves, gown, facemask).” In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed by the agency’s policy.. HOME VISIT 2: The patient elected the hospice benefit on 06/06/2026 with a terminal diagnosis of cerebrovascular disease. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 08/03/2026, the RN donned gloves to perform wound care, removed the gloves, and donned a new pair of gloves without performing hand hygiene. In an interview on 08/03/2026, the RN Patient Care Coordinator (PCC), who was present for the visit, confirmed the finding, stating, that the RN did not follow the agency’s policy to perform hand hygiene after removing gloves and donning a new pair of gloves.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) clinical records reviewed, the agency did not document infection control education for employees. PERSONNEL RECORD 10: This Volunteer was hired and onboarded on 04/13/2026. A personnel record review and a review of the Volunteer’s education records revealed no evidence that the Volunteer was provided education on infection control. During a joint personnel review on 08/05/2026, the Volunteer Coordinator and the Regional Human Resources Director confirmed that there was no documentation that the Volunteer received infection control education.”

“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 1 of 12 (8%) clinical records reviewed of patients who received Hospice Aide services (HA), the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 1: This patient elected the hospice benefit on 06/16/2025 with a terminal diagnosis of cerebrovascular disease. The patient was diagnosed with aspiration pneumonia on 09/18/2025. The hospice plan of care dated 06/11/2026-08/09/2026 ordered HA visits 3XW. The RN comprehensive assessment dated 07/15/2026 documented that the patient was diagnosed with dysphagia on 10/07/2025. The Patient Care Coordinator stated on 08/04/2026 that the patient was started on albuterol sulfate inhalation solution (2.5 mg/3ml) every 4 hours as needed for wheezing. The HA care plan was reviewed for 06/11/2026-08/09/2026 and did not include aspiration/dysphagia precautions. During an interview conducted on 08/04/2026, the Director of Regulatory Compliance and Quality stated that dysphagia was not on the Hospice Aide’s care plan for 06/11/2026-08/09/2026 as it should have been.”

“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. During an interview with the Volunteer Coordinator on 08/04/2026 and review of the Hospice Volunteer Program Annual reports for the calendar years 2024 and 2025, it was revealed that the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Hospice Volunteer Services Annual Reports documented volunteer hours of 1.18% for calendar year 2024 and 0.21% for calendar year 2025. During an interview, the Volunteer Coordinator stated that they were in this position for less than a year and were working to rebuild the program. The program included four (4) volunteers, with evidence of recruitment and retention for the years 2024, 2025, and 2026. During an interview with the Volunteer Coordinator on 08/04/2026 and review of the Hospice Volunteer Program Annual reports for calendar years 2024 and 2025, it was revealed that the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Hospice Volunteer Services Annual Reports documented volunteer hours of 1.18% for 2024 and 0.21% for 2025. During an interview, The Volunteer Coordinator stated that he was at this position for less than a year and was working to rebuild the program. The program included four (4) volunteers with evidence of recruitment and retention for the years of 2024,2025, and 2026.”