Halcyon Home LLC

“Based on record review and interview, the agency failed to have documented aide supervisory visits in one out of 17 patient records reviewed (Patient 1). This failure could place patients at risk of substandard care by hospice aides because the agency was unable to review the record to ensure supervisory visits were actually being performed. Findings included: Review of Patient 1’s clinical record revealed a document titled, “Hospice Certification and Plan of Care,” dated for the period of 5/29/26 to 8/26/26, which showed Patient 1 had a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks) and was to receive skilled nursing visits twice a week for 13 weeks, along with Hospice aide visited three times a week for twelve weeks, then twice a week for one week. Review of Patient 1’s clinical record for the certification period of 5/29/26 - 8/26/26 revealed nursing notes for the following dates, all signed by RN D: 6/4/26, 6/11/26, 5/29/26, 6/2/26 6/10/26, 6/25/26, 6/26/26, 7/1/26, 7/2/26, 7/6/26, 7/8/26, 7/15/26, 7/29/26, 8/5/26, and 8/12/26. All of these notes included the following under the subheading “Supervisory Functions”: “Were Supervisory Functions performed? NO. Indicate reason supervising functions not performed: NOT APPLICABLE TO TODAY’S VISIT.” An interview was completed with ASN at 10:45 AM on 8/19/26. ASN stated that he reviewed the record as well, and it appeared the visits had been plotted as “RN11” visits which was a regular SN visit instead of “RN10” which was an SN visit with aide supervisory functions. He stated the nurse still could have performed supervisory functions at an RN10 visit, but that he went into RN D’s notes and it appeared she selected “No” when the note asked, “Were supervisory functions performed?” The ASN confirmed that this was a failing on the nurse’s part. An interview was conducted with the Administrator at 12:15 PM on 8/20/26. When asked what the agency’s policy was on hospice aide supervision, the Administrator reported that their policy was that the RN’s should perform aide supervisory visits a minimum of every 14 days. She stated that they train RNs to perform supervisory functions, as in, checking in with the patient /family to ensure they are satisfied with the aide’s services, and ensuring aide tasks are being completed, at every visit. She stated they have a way of coding the visits on the schedule so that they appeared as an “RN Supervisory Visit” on the schedule and then the nurse was required to chart on the supervisory functions that were completed. When asked who was responsible for ensuring the supervisory visits for aides are performed every 14 days and documented in the clinical record, the Administrator stated it was the RN’s responsibility to include that in her note. When asked why it was important to patient care to ensure the supervisory visits are both completed and documented in the clinical record, the Administrator stated because they have an unlicensed individual in the home and they were responsible for their actions. She stated that they as an agency needed to ensure the patient received the care they needed from the hospice aide, and that they could not ensure that unless the RN was documenting supervisory visits. An interview was conducted with RN D at 12:30 PM on 8/20/26. The Surveyor asked why she did not document any supervisory visits for Patient 1 for the period reviewed, RN D stated that she had performed supervisory functions for Patient 1 and initially described completing one in-person supervisory visit with a former aide where she assisted the aide with bathing Patient 1. When asked how often supervisory visits should occur, RN D said she did them every 3 weeks. When asked what the agency’s policy was on supervisory visit frequency, she stated it was every month. The Surveyor informed her that the agency’s policy stated that aide supervisory visits should occur every 14 days, but that the aide does not need to be present for supervisory functions to be performed. RN D then clarified that although she did not consistently document supervisory functions in the clinical record, she routinely performed those functions during her regular visits. RN D stated that she communicated with aides weekly, and sometimes multiple times per week, regarding the patient’s care and performance of assigned duties. She also stated that she routinely communicated with the patient ’s family regarding the aide’s performance and ensured at her visits that they were completing assigned tasks. When asked why she consistently documented “No” on her notes in the field that asked, “Were supervisory functions performed?” RN D stated she was not sure and said it must have been an error when she was quickly clicking through the questions in the note documentation field. RN D acknowledged that this was an oversight. RN D stated that she believed documenting on the supervision of aides was important to ensure that there was record that she was supervising the aides and ensuring they performed their duties. Review of the agency’s policy titled, “Employee Supervision,” last reviewed 12/6/24, read in part: “A registered nurse (RN) must make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the Hospice Interdisciplinary Group/Team (IDG/IDT) meet the patient’s needs. The hospice aide does not have to be present during this visit.” Further review of the policy revealed the following: “Supervision will be performed within the time frame defined by the policy. III. The information required will be defined by the appropriate supervisory area for documentation.””