Deaconess Hospice

“Based on record review and interview, the agency failed to ensure an RN completed on-site supervisory visits for hospice aides every 14 days for 3 of 11 active records reviewed. (Patients #3, #4, and #6) Findings include: 1. Review of a revised 01/27/2025 policy titled 33.08, Nursing Service indicated, but was not limited to, “…Procedure: …1. Duties and Responsibilities: Registered Nurse…Prepares written instructions and provides supervision for home health aides (HHAs)…”. 2. Review of a revised 04/17/2023 policy titled 33.16, Supervision of Paraprofessionals indicated, but was not limited to, “…Policy: …2. Per the Condition of Participation Interpretive Guidelines G-228: If the patient receives skilled nursing care, the Registered Nurse (RN) must perform the supervisory visit…Associated Documents and Resources:…Indiana Medicare-Home Health Aide with a Skill Every 14 days, Aide may or may not be present…” 3. The Clinical Record for Patient #3, benefit period 02/17/2025 - 04/17/2025 evidenced an order on the POC for aide services two (2) time a week to provide assistance with direct and indirect activities of daily living. The aide visited Patient #3 on 02/17/2025, 02/21/2025, 02/24/2025, 02/28/2025, 03/03/2025, 03/07/2025, 03/10/2025, 03/14/2025, 03/14/2025, 03/17/2025, 03/21/2025, 03/24/2025, 03/28/2025, 03/31/2025, 04/04/2025, 04/07/2025, 04/11/2025, and 04/14/2025. The RN failed to complete an on-site supervisory visit between 03/11/2025-04/01/2025, which did not adhere to every 14 days as required. 4. The Clinical Record for Patient #4, benefit period 02/02/2025 - 05/22/2025 evidenced an order on the POC for aide services two (2) time a week to provide assistance with direct and indirect activities of daily living. The aide visited Patient #4 on 02/25/2025, 02/27/2025, 03/03/2025, 03/06/2025, 03/10/2025, 03/13/2025, 03/17/2025, 03/20/2025, 03/24/2025, 03/27/2025, 03/31/2025, 04/03/2025, 04/07/2025, 04/10/2025, 04/15/2025 and 04/19/2025. A supervisory visit was only completed on 04/09/2025 and 04/16/2025. The RN failed to complete supervisory visits every 14 days between 02/02/2025 - 04/08/2025 required to maintain compliance and in line with agency policy. 5. The Clinical Record for Patient #6, benefit period 02/24/2025 - 05/24/2025 evidenced an order on the POC for aide services two (2) times a week for the first week and three (3) time a week thereafter to provide assistance with direct and indirect activities of daily living. The aide visited Patient #6 on 02/26/2025, 02/28/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/14/2025, 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/26/2025, 03/28/2025, 03/31/2025, 04/02/2025, 04 04/04/2025, 04/07/2025, 04/09/2025, 04/11/2025, 04/14/2025, 04/16/2025, and 04/18/2025. The RN failed to complete an on-site supervisory visit between 03/19/2025-04/10/2025, which did not adhere to every 14 days as required. 6. During an interview on 04/22/2025 at 4:10 PM, the Director of Nursing (Administrator) indicated supervisory visits for aide services should occur every 14 days. The administrator could provide no reason why supervisory visits were not completed and he/she has educated on this regularly.”

“Based on policy review and interview, the agency failed to assure hospice staff furnished orientation on hospice philosophy, policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying at all facilities that provide care to hospice patients for 4 of 4 active contracted facilities housing hospice patients, with the potential to affect all contracted facilities housing hospice patients. (Entities #1, 2, 3, and 4) Findings include: 1. Review of a revised 01/02/2025 policy titled 83.06, Hospice Care for Nursing Facility Residents - Written Agreements indicated, but was not limited to, “…Procedure: …3. Provisions in the written agreement include but are not limited to: Hospice employees ensure that facility staff providing care to Hospice patients is oriented to the Hospice philosophy of care, pain control, symptom management, principles of death and dying, patients right and documentation of requirements…”. 2. Review of a signed contract dated 07/28/2024 with Entity 1 indicated, but was not limited to, “…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice’s symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility’s policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…” 3. Review of a signed contract dated June 19, 2024 with Entity 2 indicated, but was not limited to, “…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice’s symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility’s policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…” 4. Review of a signed contract dated 04/08/2025 with Entity 3 indicated, but was not limited to, “…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice’s symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility’s policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…” 5. Review of a signed contract dated June 19, 2024, with Entity 2 indicated, but was not limited to, “…IV. HOSPICE SERVICES AND RESPONSIBILITIES…4.16. Orientation and Education. Both parties shall provide sufficient orientation and in-service education to personnel to acquaint them with the Hospice’s and the Facility’s philosophy of care and services. The parties agree to each provide orientation to the other party’s employees, contractors agents, and volunteers regarding their respective policies, procedures, and services that will be provided. The Hospice will offer in-services at a variety of times so as to accommodate the Facility’s employees on all shifts. In addition to the Hospice’s philosophy, content will include discussion of the Hospice IDG and its role in care planning, palliative care and symptom control practices, as well as the responsibilities of both the Hospice and Facility…” 6. During an interview on 04/23/2025 at 2:00 PM, the Director of Nursing (Administrator) was asked if there was any documentation that assured the education sent to facilities was completed and by who as written in the contracts signed by the facilities and the hospice? The administrator could not provide any evidence of completed training by the facility staff, in-services provided by either entity, and/or who provided it and how often to allow for staff turnover within facilities. The administrator indicated that sending the training to the facilities did not comply with the written contracts for the facilities and did not assure the hospice in any way the facility did provide the training for their staff.”