Affinis Hospice, LLC

“Based on review of records, staff interviews, and review of policy titled “;Initial Assessment/Comprehensive Assessment,” it was determined the hospice Registered Nurse (RN) failed to ensure that the initial assessment was completed within 48 hours after the election of hospice care for eight patients (P) (P#1, P#3, P#4, P#6, P#7, P#10, P#11, P#12) of 15 patients sampled. The findings include: Review of the undated policy titled “;Initial Assessment/Comprehensive Assessment”, Page 1, reveals the following: Policy: The Hospice RN must complete an initial assessment within 48 hours after the election of hospice care. 1. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 5/31/2024 reveals P#1 was admitted on 5/31/2024. The initial skilled nurse assessment was signed on 6/4/24, four days after the election of hospice care. 2. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 5/22/2024 reveals P#3 was admitted on 5/22/2024. The initial skilled nursing assessment was signed on 5/27/24, five days after the election of hospice care. 3. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 3/5/2024 reveals P#4 was admitted on 3/5/2024. The initial skilled nursing assessment was signed on 3/9/24, four days after the election of hospice care. 4. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 1/26/2024 reveals P#6 was admitted on 1/26/2024. The initial skilled nursing assessment was signed on 1/29/2024, three days after the election of hospice care. 5. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 5/7/2024 reveals P#7 was admitted on 5/7/2024. The initial skilled nursing assessment was signed on 5/10/2024, three days after the election of hospice care. 6. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 4/24/2024 reveals P#10 was admitted on 4/24/2024. The initial skilled nursing assessment was signed on 4/29/24, five days after the election of hospice care. 7. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 12/16/2022 reveals P#11 was admitted on 12/16/2022. The initial skilled nursing assessment was signed on 12/20/22, four days after the election of hospice care. 8. Review of the document titled “;Skilled Nursing Visit Note Comprehensive Initial Assessment” dated 4/12/2024 reveals P#12 was admitted on 4/12/2024. The initial skilled nursing assessment was signed on 4/15/24, three days after the election of hospice care. The clinical records failed to reveal that the Comprehensive Initial Assessments were completed within 48 hours. On 6/11/24 at 3:09 p.m., an interview was conducted with Registered Nurse (RN) AA and RN BB who revealed they did not know why they completed the initial assessment late. On 6/11/24 at 3:18 p.m., an interview was conducted with the Director of Nursing (DON), who said she did not know why theyre unable to complete the nursing admission assessment within 48 hours. The DON also confirmed that all surveyors were given all available documentation for the patients records.”

“Based on record view, review of policy titled “;Hospice Care Services - Volunteer Services,” and staff interview it was determined that the agency failed to recruit and retain volunteer staff. Findings include: Review of the undated policy titled “; Hospice Care Services - Volunteer Services “, Page 1, reveals the following: Policy: The hospice agency will document active and ongoing efforts to recruit and retain volunteers. The hospice agency will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in amount that at a minimum equals 5% of total patient care hours of all paid hospice associates and contract staff RN must complete an initial assessment within 48 hours after the election of hospice care. Review of the “;Volunteer Services Activity Report” dated 7/6/2023 revealed the following: Cost Savings: Total Volunteer % : 0.00%. YTD (year to date) Volunteer % : 0.00%. On 6/11/2024 at 2:30 p.m., an interview was conducted with the Administrator who confirmed the agency had been unable to recruit and retain volunteer staff. The Administrator stated that it had been an ongoing problem and had initiated a PIP in September 21, 2023, but had continued to be unsuccessful in recruitment of volunteers till present.”