Continuum Care of Snohomish, LLC

“It is required that 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. 4 of 15 (27%) clinical records reviewed in which hospice aide (HA) services were accepted revealed the agency did not ensure the registered nurse (RN) provided specific written instructions for the HA. CLINICAL RECORD 1: The HA care plan dated 08/08/2025 included the following tasks: “Bathing-shower, dressing, hair care, nail care (file and clean), oral care-swab, skin care-apply lotion after bathing, change linens-weekly and if soiled, date of last BM (bowel movement), companionship, nurse-notify RNCM (registered nurse case manager) of change of condition, oxygen precautions.” All tasks were to be completed every visit with the exception of the linens. The HA visit frequency was twice weekly. A physician’s order dated 08/13/2025 noted the following: “Coccyx wound. Skin prep peri-wound and cover with foam dressing.” The HA care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 12: The HA care plan dated 03/10/2025 included the following tasks: “Bathing-bed bath, dressing, hair care, nail care-file and clean, oral care, peri care, shampoo, skin care-notify RNCM if any changes, turn and position in bed, change linens-weekly and if soiled, date of last BM, oxygen precautions.” All tasks were to be completed every visit with the exception of the linens. The HA visit frequency was twice weekly. A physician’s order dated 03/10/2025 noted the following: “Hospice nurse to provide wound care to stage III pressure injury on right hip utilizing clean technique. Cleanse with wound spray and pat dry. Cover with 6 x 6 foam silicone dressing and change every 7 days. Hospice nurse to perform wound care to Stage II pressure injury to right upper buttocks....cover with 4 x 4 foam silicone dressing.” A physician’s order dated 08/26/2025 noted the following: “Clean the area with wound cleanser using clean technique, pat dry, apply medi-honey to the affected area and cover it with 4 x 4 dressing. Change the dressing twice in the week or as needed.” The HA care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 15: The HA care plan dated 08/25/2024 included the following tasks: “Bathing-shower and bathing-bed bath” with a note in the details section that read “provide bed bath if patient is too weak”. Both bath types were marked “every visit” and the HA visit frequency was twice weekly. For the HA to make a decision between bath types is outside of the aide’s scope of practice. CLINICAL RECORD 16: The HA care plan dated 06/11/2025 included the following tasks: “Bathing-bed bath, hair care-brush/comb patient’s hair, nail care-clean/file, perineal care, shampoo, skin care-notify RNCM of any skin changes, turn and position in bed, change linens-weekly or if soiled, offer fluids, aspiration precautions, intake, notify nurse-change of condition-skin, pain, respiratory, nausea, vomiting, LOC (level of consciousnous). The HA care plan was updated 07/07/2025 to included the following: “Bathing-bed bath, hair care-brush/comb patient’s hair, nail care-clean/file, perineal care, turn and position in bed, change linens-weekly or if soiled, offer fluids, aspiration precautions, intake, notify nurse-change of condition-skin, pain, respiratory, nausea, vomiting, LOC, companionship.” All tasks were to be completed every visit with the exception of the linens. The HA visit frequency was twice weekly. A physician’s order dated 06/05/2025 noted the following: “Coccyx pressure injury cover with bordered foam dressing.” A physician’s order dated 07/14/2025 noted the following: “Coccyx pack with alginate then cover with bordered foam dressing.” The HA care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. A joint clinical record review and interview was conducted on 11/20/2025 with the Clinical Director/Educator during which time she stated the aide(s) should have been “provided notification of the wounds and if they needed to protect the bandages or notify the nurses if something happened during bathing.” She also advised, in the case of Clinical Record 15, the aides “could only be assigned one type of bath.””

“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. 2 of 15 (13%) clinical records reviewed in which hospice aide (HA) services were accepted revealed the agency did not ensure HA provided services included in the plan of care. CLINICAL RECORD 1/HOME VISIT 1: The HA care plan dated 08/08/2025 included the following tasks: “Bathing-shower, dressing, hair care, nail care (file and clean), oral care-swab, skin care-apply lotion after bathing, change linens-weekly and if soiled, date of last BM (bowel movement), companionship, nurse-notify RNCM (registered nurse case manager) of change of condition, oxygen precautions.” All tasks were to be completed every visit with the exception of change linens. The HA visit frequency was three times weekly. An observed home visit was conducted with the HA (PERSONNEL RECORD 7) on 11/17/2025 at 1 PM. The patient resided in a Skilled Nursing Facility (SNF) stated. “she was checking the care plan for any changes and that the patient had the option between a bed bath and a shower.” The HA showed the aide care plan on her device to the site visitor which matched the printed care plan however only showed a shower. Before entering the patient’s room, the HA checked the shower room “to see if it were open for the patient to shower.” Once in the patient’s room, the HA asked the patient if she wanted a bed bath or shower and proceeded to give her a bed bath. A bed bath was not assigned on the plan of care. She documented “Shower-N; bed bath instead.” The Clinical Educator/Director was interviewed on 11/17/2025 and had updated the aide care plan to add the wound and changed to a bed bath but advised the “aide should not have given a bed bath without calling first.” The care plan was updated on 11/17/2025 at 16:48 PM to “bathing-bed bath do not wet or soil wound dressing to coccyx. Notify RNCM/facility nurse if not present/soiled. dressing, hair care, nail care (file and clean), oral care-swab, skin care-apply lotion after bathing, change linens, date of last BM (bowel movement), companionship, nurse-notify RNCM of change of condition, oxygen precautions, safety precautions.” CLINICAL RECORD 3: The HA care plan dated 10/27/2025 included the following tasks: “Bathing-shower-shower chair dependent, shampoo, hair care, skin care, nail care (file and clean), perineal care, oral care-swab, skin care-apply lotion after bathing, change linens-weekly and if soiled, date of last BM, companionship, nurse-notify RNCM of change of condition, oxygen precautions, turn and position in bed, transfer from bed to chair, transfer from chair to bed, offer fluids, empty trash, companionship. Updated 10/28/2025 to add assist to toilet “every visit as needed”. All tasks were to be completed every visit. The HA visit frequency was twice weekly. The HA visit dated 11/18/2025 noted “bathing-shower N; gave bed bath.” Bed bath was not assigned on the HA care plan. A joint clinical record review and interview was conducted on 11/20/2025 with the Clinical Director/Educator during which time she advised the aides were not “supposed to deviate from the plan of care without notifying the nurses to change it first and there would be a lot of education to be provided.””