Interim Healthcare Hospice & Palliative Care

“It is required that the hospice designates a registered nurse member of the IDG to: ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed in which the patient received Spiritual Counselor services, the agency did not ensure that services provided to patients and families followed the individualized plan of care established by the hospice IDG. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/10/2025. The plan of care dated 01/09/2026 ordered a Spiritual Counselor (SC), one (1) visit monthly. There were documented SC visits dated 01/09/2026 and 01/19/2026. A clinical record review revealed no physician order for the second visit, nor was there documentation of communication with the ordering physician regarding the extra SC visit. SC services were not provided as ordered by the Interdisciplinary Group. The Director of Clinical Services (DCS) was interviewed on 03/03/2026 and stated, “The chaplain should have gotten an order for the extra 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 interview and observation. Agency policy “Engineering Controls and Work Practices” (dated 12/19/2022) stated in part, “Handwashing: 1. Employees who encounter patients or regulated biohazardous waste practice the following good hand-washing behaviors to reduce exposure and prevent the spread of bloodborne pathogens and other infections. Employees wash their hands: ...b) Prior to patient care or interventions (e.g., aseptic task),...d) Immediately before applying gloves and other PPE, e) Immediately after removal of gloves and other PPE, f) When moving from a contaminated body site to a clean body site during patient care.” In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per agency policy. HOME VISIT 1: During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 03/03/2026, the HA bathed the patient in the bathroom as the patient sat on the toilet. After bathing, the HA assisted the patient with dressing and transferring to their wheelchair. The HA wheeled the patient to the bathroom sink and brushed the patient’s teeth. The HA doffed their gloves and donned a new pair. The HA donned the same pair of gloves for all of these activities, did not perform hand hygiene when moving from a contaminated body site to a clean body site during patient care, and did not disinfect their hands between glove changes, per the agency’s policy. During an interview on 03/03/2026, the Director of Clinical Services (DCS), who was present during the home visits, stated, “The clinicians did not follow policy on handwashing.””

“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 1 of 3 (33%) home visits observed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 11/29/2024 with diagnoses of congestive heart failure (CHF). The patient resided in an assisted living facility (ALF). The HA care plan dated 02/20/2026 assigned the HA the task: “Perform perineal care.” No other personal care or bathing tasks were assigned on the care plan. During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 03/03/2026, the HA bathed the patient in the bathroom as the patient sat on the toilet. After bathing, the HA assisted the patient with dressing and transferring to their wheelchair. The HA wheeled the patient to the bathroom sink and brushed the patient’s teeth. During an interview following the home visit, the HA stated that they asked the patient at each visit what type of bath they wanted, since none had been assigned in the care plan. The HA stated that some days the patient is tired and wants a bed bath. The HA care plan written by the Registered Nurse (RN) did not include specific tasks for the HA to meet the patient’s needs. During an interview, the Director of Clinical Services (DCS), who was present during the home visit, stated, “The aide care plan should include specific personal care.””

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home visits observed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 11/29/2024 with diagnoses of congestive heart failure (CHF). The patient resided in an assisted living facility (ALF). The HA care plan dated 02/20/2026 assigned the HA the task: “Perform perineal care.” No bathing or other personal tasks were assigned in the care plan. During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 03/03/2026, the HA bathed the patient in the bathroom as the patient sat on the toilet. After bathing, the HA assisted the patient with dressing and transferring to their wheelchair. The HA wheeled the patient to the bathroom sink and brushed the patient’s teeth. During an interview following the home visit, the HA stated that they asked the patient at each visit what type of bath they wanted, since none had been assigned in the care plan. The HA care plan did not assign the HA the tasks provided during the visit.”

“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. The hospice documents the cost savings achieved through volunteers. 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 in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency’s Volunteer Program was reviewed with the Volunteer Coordinator on 03/03/2026. Documentation revealed that the agency’s utilization of hospice volunteers was 3.31% for the period 01/01/2024 through 12/31/2024 and 2.29% for the period 01/01/2025 through 12/31/2025. The agency did not provide volunteer services for 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 Volunteer Coordinator (VC) (Personnel Record 8) was interviewed on 03/03/2026 and stated, “We are working to get new volunteers, but it’s been difficult. We haven’t been able to reach 5% in the last few years.” The agency did not ensure 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.”