Longwood Hospice

“Based on record review and interview, the agency failed to ensure the hospice interdisciplinary group (IDG) (in collaboration with the individual’s attending physician, if any) must review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for 9 patients (#6, #8, #9, #11, #7, #10, #12, #13 and #14) out of a total sample of 14 patients.Findings include: 5. Patient #7 was admitted to the agency in 2/2024 with a primary diagnosis of senile degeneration of brain.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/25/25 through 4/24/25 and 4/25/25 through 6/21/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.6. Patient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the clinical record indicated IDG meetings were held for certification period of 3/25/25 through 5/23/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.7. Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/4/25 through 4/4/25 and 4/5/25 through 6/3/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.8. Patient #13 was admitted to the agency in 11/2023 with a primary diagnosis of Alzheimer’s disease.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/24/25 through 4/24/25 and 4/25/25 through 6/23/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.9. Patient #14 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the clinical record indicated IDG meetings were held for certification period of 3/5/25 through 5/2/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting. Review of the agency’s policy entitled IDG Care Planning Process, revised February 2022, indicated the following:*The IDG included a physician member who is the Hospice Medical Director, or another Hospice Physician who is employed by or under contract with the Hospice, Registered Nurse (RN), Social Work (SW) and Pastoral or another counselor.*IDG members provide the care and services offered by Hospice and supervise the care and services.1.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranulcear Opthaloplegia (a condition that affects eye movement control due to brain damage).Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/12/25 through 4/12/25 and 4/13/25 through 6/11/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/6/25: The physician. *3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician and the RN. The attendance log indicated only the Chaplain and MSW were in attendance on the day of the meeting.*4/17/25: The physician and the SW. The attendance log indicated only the Chaplain and RN were in attendance on the day of the meeting.*5/1/25: The physician, the RN and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting. 2. Patient #8 was admitted to the agency in August 2024 with cerebrovascular disease (stroke related to impaired blood flow in the brain).Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/3/25 through 4/3/25 and 4/4/25 through 6/2/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*2/6/25: The physician.*2/20/25: The physician. *3/6/25: The physician.*3/20/25: The physician, the RN, the MSW and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting. *4/3/25: The physician.*4/17/25: The physician. *5/1/25: The physician, the MSW and the RN. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.3. Patient #9 was admitted to the agency in March 2025 with a terminal diagnosis of senile degeneration of the brain (dementia).Review of the clinical record indicated IDG meetings were held during the certification period of 3/13/25 through 6/10/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN and the MSW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician.*4/17/25: The physician and the MSW. *5/1/25: The physician, the MSW and the RN. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.4. Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer’s disease.Review of the clinical record indicated IDG meetings were held during the certification period of 3/28/25 through 6/25/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*4/3/25: The physician and the RN. *4/17/25: The physician and the MSW. *5/1/25: The physician, the RN, and the MSW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.”

“Based on record review and interview, the agency failed to ensure staff communicated with the physician when services were not provided in as orderd for 6 patients (#5, #10, #12, #6, #9 and #11) out a total sample of 14 patients.Findings included: 1. For Patient #5, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered. - For the week of 4/20/25 - 4/26/25, only 2 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.2. For Patient #10, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 3/30/25 - 4/5/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.3. For Patient #12, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits. Review of the agency’s policy entitled Physician Orders, revised June 2019, indicated the following:*Nursing and other services that require a physician’s order will be provided in accordance with the physician’s order.*Care and services provided will be in accordance with the physician orders.*Physicians shall be notified of any variance of ordered visit frequencies.1. For Patient #5, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #5 was admitted to the agency in March 2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide visits (HAVs) 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care (POC).- For the week of 4/6/25 - 4/12/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 HAVs were provided instead of the 5 as ordered. - For the week of 4/20/25 - 4/26/25, only 2 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.2. For Patient #10, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #10 was admitted to the agency in May 2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for HAVs 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the POC.- For the week of 3/30/25 - 4/5/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.3. For Patient #12, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for HAVs 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the POC:- For the week of 4/6/25 - 4/12/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits.4. For Patient #6, the agency failed to ensure there was communication shared with the physician when HAVs were not provided as ordered.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranuclear Ophthalmoplegia (a condition that affects eye movement control due to brain damage).Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HAV: 5 times a week for 9 weeks (beginning 2/12/25 through 4/12/25).Review of the clinical record indicated for the weeks of 3/9/25 through 3/15/25 and 3/30/25 through 4/4/25, only 4 HAVs were provided each week, not 5 as ordered. The record did not include documentation of the missed visits nor whether the physician was notified.5. For Patient #9, the agency failed to ensure that there was communication shared with the physician when (a) HA, (b) Medical Social Worker (MSW) and (c) Skilled Nursing (SN) visits (Vs) were not provided as orderedPatient #9 was admitted to the agency in March 2025 with a terminal diagnosis senile degeneration of the brain.Review of the physician’s ordered POC for certification period 3/13/25 through 6/10/25, included the following:(a) *HAVs: 5 times a week for 13 weeks (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25, only 3 HAVs were provided, not 5 as ordered.(b) *MSW: Assess and evaluate 3/13/25 through 3/18/25.*MSWV: 1 time a month for 3 months (beginning 4/1/25 through 6/10/25).Review of the clinical record indicated there was not a MSWV provided for the month of April 2025.(c) *SN: Assess and evaluate 3/13/25 through 3/14/25.*SNVs: 1 time a week for 13 weeks and 3 as needed (PRN) visits (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated that for the weeks of 3/16/25 through 3/22/25, 3/30/25 through 4/5/25, 4/20/25 through 4/26/25, and 4/27/25 through 5/3/25, 2 SNVs were provided, not one as ordered. The nursing notes indicated they were nursing routine and supervisory visits. Further review of the record did not include documentation that staff notified the physician of the missed HAVs and MSWV, nor the additional SNVs provided.6. For Patient #11, the agency failed to ensure HAVs were provided as ordered.Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer’s Disease.Review of the physician’s ordered POC for certification period 3/28/25 through 6/25/25, included the following:*HAV: 5 times a week for 9 weeks (beginning 3/29/25 through 6/21/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25 25, only 4 HHAVs were provided, not 5 as ordered. The record did not include documentation that the physician was notified of the missed HAV.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits. She also said staff should have also notified the physician when 2 SNVs were provided for the 4 weeks noted above , not one as ordered, for Patient #9.”

“Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care (POC), for 6 patients (#6, #9, and #11, #5, #10, #12), out of a total sample of 14 patients. Findings include: 4. For Patient #5, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered. - For the week of 4/20/25 - 4/26/25, only 2 Hospice Aide visits were conducted instead of the 5 as ordered.5. For Patient #10, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 3/30/25 - 4/5/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.6. For Patient #12, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ chart and said that the Hospice Aide visits were not provided as ordered and there was no documentation to indicate why. 1.For Patient #6, the agency failed to ensure Hospice Health Aide Visits (HHAVs) were provided as ordered.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranuclear Opthalmoplegia (a condition that affects eye movement control due to brain damage).Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HHAV: 5 times a week for 9 weeks (beginning 2/12/25 through 4/12/25).Review of the clinical record indicated for the weeks of 3/9/25 through 3/15/25 and 3/30/25 through 4/4/25, only 4 HHAVs were provided each week, not 5 as ordered.2. For Patient #9, the agency failed to ensure that (a) HHAVs, (b) Medical Social Worker Visits (MSWVs) and (c) Skilled Nursing Visits (SNVs) were provided as ordered.Patient #9 was admitted to the agency in March 2025 with a terminal diagnosis senile degeneration of the brain.Review of the physician’s ordered POC for certification period 3/13/25 through 6/10/25, included the following:( (a) *HHAV: 5 times a week for 13 weeks (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25, only 3 HHAVs were provided, not 5 as ordered.(b) *MSW: Assess and evaluate 3/13/25 through 3/18/25.*MSWV: 1 time a month for 3 months (beginning 4/1/25 through 6/10/25).Review of the clinical record indicated there was not a MSWV provided for the month of April 2025.(c) *SN: Assess and evaluate 3/13/25 through 3/14/25.*SNVs: 1 time a week for 13 weeks and 3 as needed (PRN) visits (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated that for the weeks of 3/16/25 through 3/22/25, 3/30/25 through 4/5/25, 4/20/25 through 4/26/25, and 4/27/25 through 5/3/25, 2 SNVs were provided, not one as ordered. The nursing notes indicated they were nursing routine and supervisory visits. None of the notes indicated they were coded as PRN visits.3. For Patient #11, the agency failed to ensure HHAVs were provided as ordered.Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer’s Disease.Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HHAV: 5 times a week for 9 weeks (beginning 3/29/25 through 6/21/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25 25, only 4 HHAVs were provided, not 5 as ordered.During an interview on 5/7/25 at 12:25 P.M, the Clinic Manager (CM), said for Patient #6, HHAVs were not provided as ordered and there was no documentation to indicate why the POC was not followed.During an interview on 5/7/25 at 2:15 P.M., the CM said, for Patient #9, HHAVs, SNVs and MSWV were not provided as ordered. She said there was no documentation of why visits were missed or why extra SNVs were made. She said for Patient #11, the HHAVs were not provided as ordered and there was no documentation to indicate why. She also said the POCs for Patient #9 and #11 were followed as ordered.”

“Based on observation and staff interview, the agency failed to ensure that infection control guidelines were followed for one patient (#5) of 3 home visits conducted in a total sample of 14 records. Findings include: Review of the agency’s policy titled “Hand Hygiene Policy and Compliance Program”; revised July 2021 indicated the following:*Hand hygiene will be done by all employees, volunteers and contract staff to reduce transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms.*Indications for hand hygiene are:-before and after direct patient care-before and after each patient’s procedure-when hands are soiled*Hospice will follow the Centers for Disease Control and Prevention guidelines for hand hygiene.CDC Hand Hygiene Guidelines:*Indicators for hand washing and hand antisepsis-visible dirt, blood or body fluids on the hands of health care workers.-after removing gloves.-after contact with blood, body fluids, mucus membranes, non-intact skin and wound dressing.-moving from contaminated patient body site to clean site during patient care.Review of the agency’s policy titled “Standard Precautions”; revised July 2021 indicated the following:*All healthcare workers will routinely use appropriate barrier precautions to prevent skin and mucus membrane exposure when contact with blood or other bloody fluids of any patients is anticipated.-gloves will be worn before touching blood and body fluids, mucus membranes, or non-intact skin of all patients.-gloves will be changed and hand wash after contact with each patient. Patient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the Hospice Aide Care plan for certification period of 4/1/25-6/29/25, indicated that Patient #5 is dependent on staff with daily care including hygiene (bed bath and perineal care).On 5/7/25 at 9:30 A.M., a home visit was conducted with Home Health Aide (HHA) #5, and HHA #6 to perform personal care for Patient #5. The surveyor observed HHA #5 and #6 perform hand hygiene and put gloves on and remove the patient’s soiled diaper. HHA #6 began performing perineal care to Patient #5 who was incontinent with feces. Without changing her gloves, HHA #6 reached in her carry-on luggage to get a jar of zinc oxide, opened it and took a swipe of ointment with her contaminated gloves and applied it to Patient #5’s peri area. Without changing the same gloves, she put her hand back into the bag to return the jar of ointment. At this point, the Clinical Manager (CM) who was also observing interrupted to tell HHA #6 that she needed to change her gloves and wash her hands.During an interview on 5/7/25 at 9:45 A.M., the CM said that HHA #6 cannot be reaching in and out of her bag with contaminated gloves. She said that HHA #6 needs to wash her hands and change gloves every time.”

“Based on employee file review, policy review and interview, the agency failed to ensure that 2 of 2 hospice home aides (HHA # 6 and #5) reviewed received at least l2 hours of in-service training during each 12-month period.Findings include: 2. Employee # 5 was hired on 4/21/22.Review of the employee filed indicated Employe#5 did not receive monthly in-service training in 2024 for the months of April, May, June, September, October, November and December.During an interview on 5/7/25 at 2:30 P.M., the Chief Executive Officer (CEO) said staff, including HHAs, receive monthly in-service training. She said the in-service trainings are about an hour long, so this would allow for the HHA to get the required 12 hours of training. She said Employee #5 did not get the required 12 hours of in-service training based on her review of the employee’s file. Review of the agency’s policy titled “Inservice Education”, dated February 2021, indicated the following:-Each Hospice Aide must receive at least 12 hours of in-servicing training during each 12-month period. Hospice may fulfill the annual 12-hour in-service training requirement on a calendar year basis, an employment anniversary basis or rolling 12-month basis as long as each aide meets this in-service training requirement.1.Employee # 6 was hired on 9/7/23.Review of the employee filed indicated Employee #6 did not receive monthly in-service training in 2024 for the months of May, June, September, October, November and December.During an interview on 5/7/25 at 2:30 P.M., the Chief Executive Officer (CEO) said staff, including HHAs, receive monthly in-service training. She said the in-service trainings are about an hour long, so this would allow for the HHA to get the required 12 hours of training. She said Employee #5 did not get the required 12 hours of in-service training based on her review of the employee’s file.”

“Based on record review and interview, the Hospice agency failed to ensure that a Registered Nurse (RN) supervised the Hospice aides at least every 14 days for 2 of 14 sampled patients (#5 and #8) receiving these services in a total sample of 14 patients.Findings include: 2. Patient #8 was admitted to the agency in August 2024 with a terminal diagnosis of unspecified sequelae of cerebral infarction (lack of blood supply to the brain that causes brain tissue to die).Review of the physician ordered Plan of Care for certification period 2/3/25 through 4/3/25, indicated the following:*HHAVs: 5 times a week for 9 weeks.*SNVs: 1 time a week for 9 weeks.Review of the clinical record indicated the last documented HHA supervisory visit by the nurse was 3/3/25. Nursing did not provide HHA supervision for the weeks of 3/16/25 through 3/22/25, nor the week of 3/30/25 through 4/3/25.During an interview on 5/7/25 at 12:25 P.M., the Clinical Manager said nursing did not complete the required HHA supervision every 14 days after their last one on 3/3/25. Findings include: Review of the agency policy titled “Hospice Aide Supervision”, dated June 2019, indicated the following: -Hospice Aides are closely supervised to ensure their competence in providing care. At least every fo14 days the Registered Nurse makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence. 1. Patient #5 was admitted to Hospice services on 4/2025. The physician’s orders for the certification period of 4/1/25 - 6/29/25 indicated the patient was to receive Hospice Aide services 5 times a week for 13 weeks. Review of the clinical record indicated Hospice Aide visits were made to patient #5, 16 times from 4/1/25 to 5/1/25. There was no evidence of documented Hospice Aide supervisory visits conducted by the RN for this period and not every 14 days as required. During an interview on 5/7/25 at 2:45 P.M., the Clinical Director said that Hospice Aide supervisory visit is done at least every 14 days with or without the Hospice Aide present. She reviewed patient # 5’s clinical record and said that she cannot locate any evidence of the Hospice Aide supervisory visits.”