Interim Healthcare

“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 6 (33%) clinical records reviewed, the agency did not ensure patient-specific measurable goals were identified in the patient’s plan of care. CLINICAL RECORD 1: The patient was admitted to home health services on 09/15/2025 with a primary diagnosis of unspecified dementia without behaviors/mood. The Registered Nurse (RN) visit note dated 09/15/2025 documented that the patient’s pain score was “3,” the source of pain was the patient’s back and buttocks, the pain was chronic, occurred daily but not constantly, and non-verbal pain cues observed included moaning, decreased mobility, and a decline in mood. Additionally, the visit note documented, “The patient is unable to quantify her pain or assign a numerical rating, but can verbalize the location... observationally, she exhibits nonverbal signs of discomfort, such as wincing and groaning, particularly during repositioning or palpation...According to her daughter, the patient’s pain appears to have worsened...” The patient’s medication profile documented “morphine sulfate 20mg/ml: 0.5ml sublingually every 2 hours as needed for pain.” The patient had previously taken “methocarbamol 500mg oral tablets twice a day as needed for pain” and Tylenol Extra Strength 500mg tablets, two (2) tablets three times daily as needed. The plan of care for the benefit period dated 09/15/2025 to 12/13/2025 identified a problem with pain with interventions to monitor for medication side effects, educate the caregiver on nonverbal pain cues, and report pain unrelieved by the pain management plan. The goal for the patient to exhibit a decrease in pain-related behavior was not defined or measurable. CLINICAL RECORD 4: The patient was admitted to home health services on 10/13/2025 with a diagnosis of malignant neoplasm of the ascending colon. The patient resided in an assisted living facility (ALF). The RN visit note dated 10/27/2025, documented that the patient rated their nausea a score of 8 and vomiting a score of 7, both symptom scores indicating that the symptoms were severely impacting their quality of life and that the nausea had been more frequent. On 10/29/2025, the RN visit note documented that the patient’s nausea score had decreased to “3” and vomiting to “1,” with a slight impact on their experience of quality of life. The patient’s medication profile documented: pantoprazole sodium 40mg delayed-release tablet, one (1) tablet orally daily for reflux; Mylanta Maximum Strength 400-400-40mg/5ml oral suspension, 30ml by mouth every 4 hours as needed for heartburn and/or upset stomach, and promethazine hcl 12.5mg by mouth every 6 hours as needed for nausea/vomiting. On 10/27/2025, the previously as-needed ondansetron 8mg oral disintegrating tablet, administered orally three times daily for nausea/vomiting, was changed to a regular dosing schedule of three times daily. The plan of care for the benefit period dated 10/13/2025 to 01/10/2026 identified a problem with nausea and vomiting. The POC intervention documented educating the patient and caregiver on the medications used, including dose, route, and frequency, to achieve optimal antiemetic function. The documented goal that the patient would report relief of symptoms was not measurable. During a joint review of the plan of care goals and an interview on 11/06/2024, the Clinical Director stated that they would not know how the goals would be assessed as met, given that there was no measurable outcome.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed a competency evaluation program described below. A qualified hospice aide has successfully completed a competency evaluation program that: 1) Evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 2) Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. This standard was not met as evidenced by clinical record review, personnel record review, and interview. In 1 of 1 (100%) personnel records reviewed of a Hospice Aide (HA), the agency did not ensure that the Hospice Aide was observed performing all skills with a patient or pseudo-patient. PERSONNEL RECORD 8: A review of the personnel record for the Hospice Aide (HA) hired on 11/19/2024 revealed that neither the “Skills Evaluation & Experience Checklist” dated 09/18/2025 nor the “Hospice Aide Supervisory Visit” dated 09/24/2025 indicated satisfactory observation of skills for the shower chair or assisting with ambulation, with a patient or pseudo-patient. A clinical record review revealed that the HA care plan for Clinical Record 3, effective 10/09/2025, assigned the HA the task of assisting the patient with ambulation. A review of Clinical Record 4, which did not include a HA care plan, revealed that the HA visit notes documented the provision of showers with a shower chair to the patient. During a joint review of the agency’s clinical competency form, supervisory visit form, and an interview on 11/06/2025, the Hospice Clinical Director confirmed that the skills had not been documented as observed at the time of the HA’s hire due to only two patients being served by this start-up hospice that had not required those skills. No follow-up or updated competency assessments were completed for new patients who required these tasks upon admission.”

“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 3 of 5 (60%) clinical records of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 09/15/2025 with a primary diagnosis of unspecified dementia without behaviors/mood. The plan of care for the benefit period dated 09/15/2025 to 12/13/2025 ordered Hospice Aide (HA) services twice a week. The HA care plan, effective 09/22/2025, assigned the HA the relevant tasks: bed baths and incontinent care at each visit. The Registered Nurse’s (RN) start-of-care visit note dated 09/15/2025 documented that the patient was incontinent of bowel and bladder and had a Foley catheter. The following wounds were documented: an unstageable left hip wound measuring 3cm x 5.8cm x 1cm, an unstageable sacral wound measuring 3cm x 4.3cm x 0.1cm, a stage 2 lower back wound measuring 2.2cm 1.1cm x 0.1cm, and a stage 2 left buttock wound measuring 2.2cm x 3.2cm x 0.1cm. The physician’s order dated 09/15/2025 ordered wound care three times a week to the patient’s left hip, sacrum, buttocks, and back, “cleansing and irrigating the wounds with a wound cleanser and patting them dry. Apply Medihoney and a bordered foam dressing to the left hip and sacral wounds.” On 10/06/2025, the physician’s order was updated: “cleanse and irrigate the wounds with wound cleanser and pat dry. For the left buttock wound, pack with Vashe moistened packing strips and cover with a bordered foam dressing. For the left hip and sacrum, apply Medihoney followed by a bordered foam dressing.” The HA plan of care prepared by the RN did not provide the HA with instructions should the patient’s dressings become dislodged, wet, or soiled. CLINICAL RECORD 2: The patient elected hospice care on 09/22/2025 with a primary diagnosis of unspecified dementia without behaviors/mood. The plan of care for the benefit period dated 09/22/2025 to 12/20/2025 ordered HA services three times a week. The HA care plan assigned the HA the relevant task: shower with a shower chair each visit. The RN’s start-of-care visit note dated 09/22/2025 documented that the patient was incontinent of bowel and bladder and had a stage 3 right hip wound measuring “2.5cm x 1.3cm x 0.4cm,” an unstageable left hip wound measuring “3cm x 5.8cm x 0.1 cm,” an unstageable sacral wound measuring “3cm x 4.3cm x 0.1cm,” and a stage 2 left buttock wound measuring “2cm x 3.2cm x 0.1cm.” The initial plan of care for the benefit period dated 09/22/2025 to 12/20/2025 ordered wound care three times a week: “cleanse the wound with normal saline and pat dry. Apply a mixture of 2 vancomycin capsules and 1 gentamicin/clindamycin/ mupirocin capsule mixed with iodosorb gel and SilvaSorb hydrogel to the wound bed and undermining. Cover with an ABD pad and a bordered foam dressing.” The HA plan of care prepared by the RN did not provide the HA with instructions should the patient’s dressings become dislodged, wet, or soiled. CLINICAL RECORD 4: The patient elected hospice care on 10/13/2025 with a diagnosis of malignant neoplasm of the ascending colon. The patient resided in an assisted living facility (ALF). The plan of care for the benefit period dated 10/13/2025 through 01/10/2026 ordered HA services initially twice a week, then three times weekly. The first HA visit note was dated 10/14/2025. A clinical record review revealed no HA care plan, which left the HA to consider all potential interventions that could be assigned. During a joint record review and interview on 11/06/2025, the Hospice Clinical Director (HCD) confirmed that there was no HA care plan for Clinical Record 4. The HCD initially stated that the patient did not accept HA services, and therefore, no plan of care was documented upon admission and was never updated. Additionally, the HCD confirmed that there were no wound care instructions for the HA in Clinical Records 1 and 2, because they did not consider the possibility that the patients’ dressings might become dislodged, wet, or soiled; therefore, no instructions were provided. The records were updated and brought into compliance before the conclusion of the site visit.”