Aurora Hospice, Inc.

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and 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 in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed revealed the agency did not ensure that the services as ordered on the plan of care were provided to the patient. Clinical Record 2: The patient elected the hospice benefit on 01/23/2023.A review of the plan of care (POC) dated 11/13/2024 included orders for the Medical Social Worker (MSW) visit frequency of 2 visits per month with 4 PRN visits, and a Hospice Aide visit frequency of 5 times each week. There was one documented MSW visit in November 2024 on 11/21/2024, and three documented Hospice Aide visits during the week of 11/13/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. Clinical Record 4: The patient elected the hospice benefit on 08/22/2024. A review of the plan of care (POC) dated 11/20/2024 included orders for the Medical Social Worker (MSW) visit frequency of 2 visits per month with 4 PRN visits and a Hospice Aide visit frequency of five times per week. There were no documented MSW visits in the record for November 2024 and three documented Hospice Aide visits during the week of 11/20/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. Clinical Record 5: The patient elected the hospice benefit on 08/28/2024. A review of the plan of care (POC) dated 11/26/2024 included orders for the Spiritual Counselor (SC) visit frequency of 1-2 visits per month with 5 PRN visits and a Hospice Aide visit frequency of five times per week. There were no documented SC visits in the record for November 2024 and four documented Hospice Aide visits during the week of 11/26/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. Clinical Record 7: The patient elected the hospice benefit on 03/18/2024. A review of the plan of care (POC) dated 11/13/2024 included orders for the Medical Social Worker (MSW) visit frequency of 2 visits per month with 4 PRN visits. There was one documented MSW visit in the record for November 2024 on 11/19/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. Clinical Record 8: The patient elected the hospice benefit on 10/15/2024. A review of the plan of care (POC) dated 10/15/2024 included orders for Medical Social Worker (MSW) visit frequency of 2 visits per month with 4 PRN visits. There was one documented MSW visit in the record for October 2024 on 10/16/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. Clinical Record 9: The patient elected the hospice benefit on 10/10/2024. A review of the plan of care (POC) dated 10/10/2024 included orders for the Hospice Aide visit frequency of five times per week. There was one documented Hospice Aide visit during the week of 10/10/2024. There was no documented evidence that the registered nurse (RN) ensured the implementation of the interdisciplinary plan of care. The Director of Clinical Services (DCS) (Personnel Record 1) was interviewed on 12/12/2024 and stated, “[The Electronic Medical Record] does not allow us to write specific visit orders that change weekly or monthly during the hospice episode.””

“It is required that each patient’s individualized written plan of care a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 12 of 14 (86%) clinical records reviewed, the agency did not ensure that orders written for as needed (PRN) visits included an indication for when the visits are to be used. Clinical Record 1: A review of the plan of care (POC) dated 10/28/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits, and a Hospice Aide visit frequency of 5 visits per week with 2 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 2: A review of the plan of care (POC) dated 11/13/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 3: A review of the plan of care (POC) dated 11/10/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 4: A review of the plan of care (POC) dated 11/20/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 5: A review of the plan of care (POC) dated 11/26/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 6: A review of the plan of care (POC) dated 09/25/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 7: A review of the plan of care (POC) dated 11/13/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, and a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 8: A review of the plan of care (POC) dated 10/15/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, and a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 9: A review of the plan of care (POC) dated 10/10/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 5 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 10: A review of the plan of care (POC) dated 11/29/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 11: A review of the plan of care (POC) dated 05/28/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 4 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. Clinical Record 12: A review of the plan of care (POC) dated 03/17/2024 revealed a Skilled Nursing visit frequency of 1-2 visits per week with 5 PRN visits, a Medical Social Worker visit frequency of 2 visits per month with 5 PRN visits, and a Spiritual Counselor visit frequency of 1-2 visits per month with 5 PRN visits. An indication for the PRN visits for each discipline was not present in the order on the POC. The Director of Clinical Services (DCS) (Personnel Record 1) was interviewed on 12/11/2024 and stated, “[The EMR] doesn’t have a place to add reasons for PRN visits.””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that all employees received education on infection control. Personnel Record 8: A review of the personnel record (Personnel Record 8) for the Nurse Practitioner (NP) with a hire date of 12/13/2017 revealed that the employee’s record did not include documentation of education on infection control. The Director of Clinical Services (Personnel Record 1) was interviewed on 12/12/2024 and validated that education on Infection Control was not present in the personnel record.”

“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 revealed the agency did not maintain documentation of any recruitment and retention efforts for the volunteer program. A review of the agency’s Volunteer Program revealed that the agency maintains policies on Volunteer services, an educational program for volunteers, and an ongoing in-service program for volunteers. However, the Volunteer Coordinator (Personnel Record 9) was unable to provide documentation of any efforts to recruit and retain volunteers. The Volunteer Coordinator (VC) (Personnel Record 9) and Director of Clinical Services (DCS) (Personnel Record 1) were interviewed on 12/12/2024. The DCS stated that the organization has only one volunteer, who is also the VC, and that no additional efforts have been made to recruit additional volunteers for the Volunteer Program. The agency did not maintain documentation of any recruitment and retention efforts for the volunteer program.”

“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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) personnel records reviewed, the agency did not ensure that competencies were completed per the agency’s policy. Document 1: The agency’s policy “HR.C10 Competency Assessment”, stated in part, “Competency evaluations are carried out by professionals that have appropriate supervisory experience in the area of expertise of the person being evaluated. (i.e. An MSW would perform a competency exam on an MSW” and a “Competency evaluation occurs during the orientation period, annually, and as needed when adverse patient outcomes are directly related to an individual’s performance.” Personnel Record 6: A review of the personnel record revealed that the competency for the position of Medical Social Worker (MSW) was last documented on 04/24/2024 by the Director of Clinical Services (DCS) (Personnel Record 1). The DCS was not a Medical Social Worker and was not the appropriate discipline to perform the competency as per the agency’s policy. Personnel Record 7: A review of the personnel record revealed that the competency for the position of Spiritual Counselor (SC) was last documented on 07/10/2024 by the Director of Clinical Services (DCS) (Personnel Record 1). The DCS was not a Counselor and was not the appropriate discipline to perform the competency as per the agency’s policy. Personnel Record 8: A review of the personnel record revealed that the competency for the position of Nurse Practitioner (NP) was last documented on 04/01/2024 by the Director of Clinical Services (DCS) (Personnel Record 1). The CRNP performed Face to Face encounters for the agency which exceeds the responsibilities of an RN case manager. The DCS was not a Nurse Practitioner and was not the appropriate discipline to perform the competency as per the agency’s policy. The Director of Clinical Services (Personnel Record 1) was interviewed on 12/12/2024 and stated that she was “unaware that the competencies needed to be done by like-disciplines.””

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview, and personnel record review. In 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure that criminal background checks were completed on all hospice employees who have direct patient contact or access to patient records. Personnel Record 3: A review of the personnel record(Personnel Record 3) ( MD) with a hire date of 04/01/2020) revealed that there was no documentation in the record that a criminal background check was performed. The Medical Director was contracted directly with the agency (not through a contracting agency). The Medical Director’s contract was reviewed which included the requirement of a criminal background check. The Director of Clinical Services (Personnel Record 1) was interviewed on 12/12/2024 and stated, “There is no documentation in the personnel record of a criminal background check either by [agency] or provided by the Medical Director.””