Positive Nature Hospice LLC

“It is required that the hospice designate 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. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that medical social services were provided as ordered by the physician and established in the plan of care (POC). CLINICAL RECORD 1: The patient elected the hospice benefit on 08/18/2025 for a diagnosis of chronic obstructive pulmonary disease. Social work services were ordered monthly. A visit was performed by the spiritual counselor on 4/17/2026. There was no evidence that a social worker visited during the month of April 2026. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/18/2025. Social work services were ordered monthly. A visit was performed by the spiritual counselor on 4/30/2026. There was no evidence that a social worker visited during the month of April 2026. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/07/2025 with a diagnosis of heart failure. Social work services were ordered monthly. A visit was performed by the spiritual counselor on 4/27/2026. There was no evidence that a social worker visited during the month of April 2026. An interview and joint record review was conducted with the Administrator, Director of Nursing and Alternate Director of Nursing on 05/01/2026, during which time it was confirmed that social work visits were not completed as ordered.”

“It is required that medical social services are provided by a qualified social worker. This standard was not met as evidenced by clinical record review, interview and personnel record review. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that medical social services were provided by a qualified social worker. A review of Clinical Record 1, Clinical Record 3 and Clinical Record 4 indicated routine social work visits were ordered in the Plan of Care (POC) for a frequency of one (1) time per month. In the month of April 2026, a monthly visit was performed by an individual who was not a qualified social worker. The individual (Personnel Record 6) held a baccalaureate degree in applied science. An interview was conducted with the Administrator on 05/01/2026 who stated they (the hospice) have a social worker with a master’s degree on staff; however, she believed the applied science degree met the qualifications because the staff member was working towards a healthcare degree and he had worked as a counselor with the homeless.” A review of Clinical Record 1, Clinical Record 3 and Clinical Record 4 indicated routine social work visits were ordered in the Plan of Care (POC) for a frequency of one (1) time per month. In the month of April 2026, the visits were performed by Personnel Record 6. Clinical Record 1 visit was dated 04/17/2026, Clinical Record 3 dated 04/30/2026, and Clinical Record 4 dated 04/27/2026. A review of the Personnel Record 6 indicated that this individual did not meet the qualifications as outlined in (L787) which requires the following: A Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; A baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; A baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above. Their degree was a baccalaureate in applied science. An interview was conducted with the Administrator on 05/01/2026 who advised “they (the hospice) have an MSW (Master’s social worker on staff, however, she believed this applied science degree met the qualifications because it wos working towards a healthcare degree and he had worked as a counselor with the homeless.””

“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 1 (100%) home visits of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. Home Visit 1: The patient elected the hospice benefit on 08/18/2025 for a diagnosis of chronic obstructive pulmonary disease. Home Visit 1/Clinical Record 1 was performed with Personnel Record 7 (Hospice Aide) on 04/30/2026. During the visit, the aide was observed to remove the patient’s oxygen which was being delivered via nasal cannula and replace it after completion of other performing other ordered tasks, dressing, shampoo and hair care. The task of removing the oxygen during care was not listed on the hospice aide care plan which was last reviewed 04/29/2026. An interview was conducted with the Director of Nursing on 04/30/2026 following Home Visit 1. The Director of Nursing had been present on the Home Visit as an observer. She confirmed the oxygen removal was not included on the hospice aide care plan.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 2 (50%) personnel records of hospice aides reviewed revealed the agency did not ensure a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. Document 2: Agency policy titled “Hospice Aide Supervision PC.H40 dated 2022” stated in relevant parts: “4. A hospice RN makes an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while he or she is performing care.” PERSONNEL RECORD 8: A review of the personnel record on 04/30/2026 revealed that the hospice aide hired on 05/31/2023 contained an annual on-site visit in 2025 signed by a licensed practical nurse (LPN). There was no evidence that a registered nurse (RN) made an annual on-site visit to the location where a patient was receiving care to assess the hospice aide’s performance. An interview and joint record review was conducted with the Administrator, Director of Nursing and Alternate Director of Nursing on 04/30/2026, during which time the Administrator stated, “I thought in (name of state) an LPN could sign aide competencies.” After review of agency policy and the regulation, she said “I see where it needs to be an RN.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 9 (22%) personnel records reviewed revealed the agency did not ensure the skills and competencies of all individuals providing care, including volunteers were assessed. Document 3: Agency policy titled “Hospice Aide Supervision PC.H40 dated 2022” stated in relevant parts: “5. The supervising RN assesses the aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include but are not limited to: C. Demonstrating competency with assigned tasks.” PERSONNEL RECORD 8: A review of the personnel record on 04/30/2026 revealed that the hospice aide hired on 05/31/2023 contained an annual competency in 2025 signed by a licensed practical nurse (LPN). There was no documented evidence that a registered nurse (RN) assessed the hospice aide’s skills and competencies. PERSONNEL RECORD 7: A review of the personnel record on 04/30/2026 revealed that the hospice aide hired on 11/03/2025 contained initial competencies in 2025 were signed by another hospice aide. There was no documented evidence that a registered nurse (RN) assessed the hospice aide’s skills and competencies. An interview and joint record review was conducted with the Administrator, Director of Nursing and Alternate Director of Nursing on 04/30/2026, during which time the Administrator stated, “I thought in (name of state) an LPN could sign aide competencies.” After review of agency policy and the regulation, she said “I see where it needs to be an RN.””

“It is required that a patient clinical record contains correct clinical information including physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which a discharge order was required revealed the agency did not ensure one was documented. Document 1: Agency policy titled: “Discharge Policy PC.D20 dated 2022” stated in relevant part(s): “5. Prior to discharge the hospice agency IDG consults with the hospice agency physician, and the RN obtains a discharge order from the hospice medical director.” CLINICAL RECORD 11: The patient elected the hospice benefit on 08/13/2025 for a diagnosis of protein calorie malnutrition. The patient was discharged for extended prognosis on 02/06/2026. A review of the clinical record on 05/01/2026 revealed there was no documentation of a physician’s order for discharge. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/09/2024 for Alzheimer’s disease. The patient elected to revoke their hospice benefit on 07/18/2025. A review of the clinical record on 05/01/2026 revealed there was no documentation of a physician’s order for discharge. An interview and joint record review was conducted with the Administrator, Director of Nursing and Alternate Director of Nursing on 05/01/2026, during which time it was confirmed the discharge orders were not able to be located in the clinical record and they “should have been written there per agency policy.””

“It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; OR a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; OR a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above; AND at least one (1) year of social work experience in a health care setting OR a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) personnel records reviewed of persons with social work job descriptions revealed the agency did not ensure the individuals had appropriate degrees. PERSONNEL RECORD 6: A review of the personnel record on 04/29/2026, 04/30/2026 and 05/01/2026 revealed the individual did not meet the qualifications for the role of social worker. The employee had a bachelor’s degree in applied science. An interview was conducted with the Administrator on 05/01/2026 who advised they (the hospice) have an MSW on staff, however, she believed this applied science degree met the qualifications because they were working towards a healthcare degree and he had worked as a counselor. A review of the Personnel Record 6 indicated that this individual did not meet the qualifications as outlined in (L787) which requires the following: A Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; A baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; A baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above. Their degree was a baccalaureate in applied science. An interview was conducted with the Administrator on 05/01/2026 who advised “They (the hospice) have an MSW (Master’s social worker on staff, however, she believed this applied science degree met the qualifications because it wos working towards a healthcare degree and he had worked as a counselor.””