Every finding on record at Interim Healthcare Hospice of Ohio, Inc

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.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the home health aide provided services ordered by the Interdisciplinary Group. Clinical Record 2: The patient elected hospice care on 9/7/2023 and resided in an assisted living facility (ALF). The hospice aide care plan dated 9/8/2023 assigned the hospice aide the tasks: assist with dressing every visit, hair care every visit, and make bed every visit. The hospice aide visit notes dated 9/12/23 and 9/15/2023 documented "Not Complete" for the assigned tasks: assist with dressing every visit, hair care every visit, and make bed every visit. There was no evidence of communication with the Registered Nurse (RN) or changes to the plan of care. Clinical Record 3: The patient elected hospice care on 9/12/2023. The hospice aide care plan dated 9/12/2023 ordered the hospice aide three times a week and assigned the hospice aide the tasks: assist with upper body dressing every visit, assist with lower body dressing, apply lotion to skin every visit, apply barrier cream to buttocks three times a week, assist patient with shower three times a week, and shower chair. The hospice aide visit notes dated 9/18/2023 and 9/21/2023 documented "Not Complete" for the assigned tasks: assist with upper body dressing every visit, assist with lower body dressing, apply lotion to skin every visit, apply barrier cream to buttocks three times a week, assist patient with shower three times a week, and shower chair. There was no evidence of communication with the RN or changes to the plan of care. Clinical Record 5: The patient elected hospice care on 7/28/2023. The hospice aide care plan dated 7/28/2023 ordered the hospice aide one time a week and assigned the hospice aide the tasks: apply lotion to skin every visit, apply barrier cream to buttock every visit, perform peri care weekly, apply lotion to skin every visit, assist with shower weekly. The hospice aide visit note dated 9/26/2023 documented that the assigned task, "apply lotion to skin every visit," was not completed. On 10/3/2023, the hospice aide visit note documented the assigned tasks: apply barrier cream to buttock every visit, perform peri care weekly, apply lotion to skin every visit, and assist with shower weekly were not completed. There was no evidence of communication with the RN or changes to the plan of care. In interview on 10/9/2023, the Director of Clinical Services confirmed that the clinical record did not include documentation of the hospice aide following the care plan and discussing changes with the RN. THIS IS A CONTINUED REQUIRED ACTION; 3 of 4 (75%) of clinical records reviewed with a home health aide included in the plan of care revealed that the agency did not ensure that the aide followed the plan of care as ordered.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current, prescription and over-the-counter (OTC) drugs, supplements and other alternative treatments that could affect drug therapy. The medication review process includes the identification of actual or potential drug interactions. This standard was not met as evidenced by clinical record review and interview. 2 of 6 (33%) clinical records reviewed of patients receiving oxygen, the agency did not ensure that the drug profile included oxygen. Clinical Record 1: This patient elected hospice care on 12/19/2022. The Registered Nurse documented in the initial comprehensive assessment dated 12/19/2022 that the patient was using oxygen. The patient's drug profile did not include documentation of oxygen. Clinical Record 3: This patient elected hospice care on 01/30/2023. The RN documented in the initial comprehensive assessment dated 01/30/2023 that the patient was using oxygen. The patient's drug profile did not include documentation of oxygen. The Director of Nursing stated during an interview on 05/09/2023 that oxygen was not added to the medication profiles. No further information was provided.

It is required that the hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions This standard was not met as evidenced by clinical record review and interview. 6 of 19 (32%) clinical records reviewed, the hospice did not identify planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: This patient elected hospice care on 12/19/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) on 12/19/2022 documented the patient's problems with dysphagia, edema, and constipation. The plan of care did not include interventions and goals to address the patient's dysphagia, edema, and constipation. Clinical Record 2: This patient elected hospice care on 03/24/2023. The initial comprehensive assessment completed by the RN on 03/24/2023 documented the patient's problem with dysphagia. The plan of care did not include an intervention and goal to address the patient's dysphagia. Clinical Record 3: This patient elected hospice care on 01/30/2023. The initial comprehensive assessment completed by the RN on 01/30/2023 documented the patient's problem with dysphagia. The plan of care did not include an intervention and goal to address the patient's dysphagia. Clinical Record 5: This patient elected hospice care on 12/13/2022. The initial comprehensive assessment completed by the RN on 12/13/2022 documented the patient was a fall risk. The plan of care did not include an intervention and goal to address the patient's risk of falls and safety. Clinical Record 12: This patient elected hospice care on 06/27/2022. The initial comprehensive assessment completed by the RN on 06/27/2023 documented the patient's problem with dysphagia. The plan of care did not include an intervention and goal to address the patient's dysphagia. Clinical Record 18: This patient elected hospice care on 04/11/2023. The initial comprehensive assessment completed by the RN on 04/11/2023 documented the patient's problem with dysphagia. The plan of care did not include an intervention and goal to address the patient's dysphagia. During an interview on 05/11/2023, the Administrator/Director of Nursing stated that the plans of care did not include problems identified during the initial assessment.

It is required that each patient’s individualized written plan of care, reflects patient and family goals, and measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5.2%) clinical records reviewed, the hospice did not ensure that the plan of care included goals and measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: This patient elected hospice care on 03/24/2023. The initial RN assessment completed on 03/24/2023 documented a "caregiver knowledge deficit related to hospice care." The plan of care documented the patient/family goal, "patient caregiver will demonstrate understanding of hospice." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. During an interview on 05/11/2023, the Administrator/DON stated that the plan of care did not have goals and measurable outcomes.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 2 of 6 (33%) clinical records reviewed, the hospice did not ensure that the plan of care (POC) included the drugs necessary to meet the needs of the patient. Clinical Record 1: This patient elected hospice care on 12/19/2022. The Registered Nurse (RN) documented in the initial comprehensive assessment dated 12/19/2022 that the patient was using oxygen. The POC did not include documentation of oxygen. Clinical Record 3: This patient elected hospice care on 01/30/2023. The initial comprehensive assessment completed by the RN on 01/30/2023 documented the patient was using oxygen. The POC did not include documentation of oxygen. The Director of Nursing stated during an interview on 05/09/2023 that oxygen was not added to the medication profiles and plan of care. No further information was provided.

It is required that a hospice aide provides services that are: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 13 (23%) clinical records reviewed of patients receiving aide services, the hospice did not ensure that the hospice aide provided services that were included in the patient's plan of care. Clinical Record 8: This patient elected hospice care on 02/11/2023. The aide plan of care established by the Registered Nurse (RN) on 02/11/2023 assigned the aide the tasks: "complete shower and apply lotion every visit." The hospice aide visit notes completed on 02/15/2023, 02/17/2023, 02/22/2023, and 02/24/2023 documented that the assigned tasks: "shower and apply lotion," were not completed. There was no evidence of communication with the RN or changes to the plan of care. During an interview on 05/10/2023, the Director of Clinical Services confirmed the finding and stated that the aide gave a verbal report to the RN about tasks not completed. Clinical Record 14: This patient elected hospice care on 08/18/2022. The hospice aide plan of care established by the RN on 08/18/2022 assigned the aide the task: "shower" the patient every visit. The hospice aide visit notes completed on 09/02/2022, 11/11/2022, and 11/14/2022 documented that the assigned task: "shower," was not completed. There was no evidence of communication with the RN or changes to the plan of care. Clinical Record 13: This patient elected hospice care on 03/21/2023. The hospice aide plan of care established by the RN on 03/21/2023 assigned the aide the task: "shower" the patient every visit. The hospice aide visit notes completed on 03/22/2023, 03/27/2023, and 03/29/2023 documented that the assigned task: "shower," was not completed. There was no evidence of communication with the RN or changes to the plan of care.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure that ongoing efforts to recruit and retain volunteers were documented. A review of the hospice volunteer program documentation for 2021, 2022 and 2023 with the Quality Director revealed that the hospice did not document volunteer recruitment or retention activities for 2021, 2022, and 2023 to dated. The Quality Director stated in an interview on 05/12/2023 that the agency stopped using volunteers during COVID-19. A review of the volunteer program documentation for 2020, 2021, 2022 and 2023 with the Quality Director revealed that the agency did not document the volunteer recruitment or retention since June, 2020. The Quality Director stated in interview on 05/12/2023 that due to Covid-19 pandemic the agency stopped using volunteers and did not continue to document cost savings.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. 7 of 19 (37%) clinical records reviewed, the hospice did not ensure the written certification included the required elements. Clinical Record 2: This patient elected hospice care on 03/24/2023. The initial certification of terminal illness (CTI) completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 3: This patient elected hospice care on 01/30/2023. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 4: This patient elected hospice care on 03/13/2023. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 7: This patient elected hospice care on 01/04/2023. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 8: This patient elected hospice care on 02/11/2023. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 13: This patient elected hospice care on 03/21/2023. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 18: This patient elected hospice care on 04/11/2023 with a primary hospice diagnosis of COPD. The initial CTI completed by the hospice Medical Director documented the age of the patient and the terminal diagnosis. There was no documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. During an interview on 05/10/2023, the Administrator/DON confirmed the findings and stated that the Medical Director did not include the required information. No further information was provided.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed of patients that lived at home, the hospice did not ensure that the ability of the patient and family to administer drugs and biologicals safely was assessed or addressed. Clinical Record 4: This patient elected hospice care on 03/13/2023. The hospice provided medications for the patient. The ability of the patient and family to safely manage medications was not addressed in the comprehensive assessment or the plan of care. During an interview on 05/09/2023, the Director of Nursing stated that the interdisciplinary group did not assess the ability of the patient and family to manage the self-administration of medications in their home. No further information was provided.