Luminary Hospice

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed for patients that elected hospice services revealed that agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/17/2025 with diagnosis of Peripheral Vascular Disease. The initial comprehensive assessment dated 10/17/2025 included that the patient had a g-tube and multiple wounds. The plan of care dated 10/17/2025 did not include interventions for the g-tube or wound care. On 10/21/2025 skilled nurse visit note, the nurse documented wound care done per Plan of Care, however wound care orders were not present in the plan of care. During an interview on 11/12/2025 with the Director of Clinical Services (Personnel Record 5), she stated they have a performance improvement project in place for plans of care, but they need to reeducate and increase monitoring of plan of care to include problems identified on admission or updated comprehensive assessments.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (10%) personnel record reviewed for the hospice aides revealed that the agency did not ensure that a competency evaluation was completed by a Registered Nurse prior to providing unsupervised direct patient care. PERSONNEL RECORD 2: The personnel record review for the hospice aide hired on 06/16/2025 lacked evidence of an initial competency completed by the preceptor before the first hospice aide visit on 07/03/2025. As evidenced by the personnel record, which contains an initial competency dated 06/16/2025; however, the self-assessment was the only portion of the form that was completed. The evaluation method and competency validation, indicated by the preceptor’s initials and date, were blank. A completed initial competency was present in the personnel record dated 09/16/2025. During an interview with the Executive Director (Personnel Record 4) and the Director of Clinical Services (Personnel Record 5) on 11/10/2025, it was stated that the Registered Nurse did accompany the hospice aide on her first visit; however, she had completed the form incorrectly, so they had her redo the form and she was instructed not to back date the form so it contained the date the form was corrected. She was unable to produce the original document and stated that it was discarded and that education would be given to office manager to not discard originals and additional education to staff about completing the form timely and correctly.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical record review for patient’s that elected hospice aide services revealed that the agency did not ensure the responsible RN had written patient care instructions for the hospice aide. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/30/2025 with diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation. The hospice aide was providing care three (3) times a week. The aide care plan dated 11/05/2025 had written instructions for shower and complete bed bath with no frequency instructing the hospice aide which type of care to provide to the patient at which visit. The clinical record lacked evidence of the supervising RN providing written patient care instructions, as evidenced by the hospice aide plan of care dated 11/05/2025 During an interview on 11/12/2025 with the Director of Clinical Services (Personnel Record 5), she stated that the frequency of tasks was not identified on aide plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical record review for patients that elected hospice aide services revealed that the agency did not ensure the hospice aides reported changes in the patient’s condition was reported to the registered nurse. CLINICAL RECORD 5: The clinical record review lacked evidence of the aide reporting changes in the patient to the registered nurse, evidenced by documentation for visit provided on 11/11/2025. The hospice aide documented “patient c/o pain to right arm from previous break 2 years ago.” Also stated,” she has had SOB starting this past Saturday while doing little chores around room. She states that she is using oxygen continuously.” There was no documented evidence in the clinical record that the registered nurse was notified of the pain to right arm or shortness of breath that the patient reported. During an interview on 11/12/2025 with the Director of Clinical Services (Personnel Record 5), she stated that the registered nurse was notified but it was not documented so it did not happen.”