Ovation Hospice of Salt Lake

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the aide provided services as included in the plan of care. CLINICAL RECORD 11: The aide plan of care, dated 07/14/2025, included visit frequencies of 3 times per week, and the following tasks to be completed each visit: hair care, skin care, and oral care. The hospice aide visit on 08/18/2025 did not document the assigned tasks of hair care, skin care, or oral care were completed. The record lacked a reason why the task was not completed. CLINICAL RECORD 12: The aide plan of care, dated 05/19/2025, included visit frequencies of 5 times per week, and the following task to be completed each visit: obtain weight. The hospice aide visit notes for 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 did not document assigned task of weight every visit was completed. The record lacked a reason why the task was not completed. CLINICAL RECORD 14: The aide plan of care, dated 08/01/2025, included visit frequencies of 3 times per week, and the following task to be completed each visit: hair care, skin care, foot care, oral care, elimination and home management. The hospice aide visit note dated 08/20/2025 did not document that the assigned tasks of hair care, skin care, foot care, oral care, elimination or home management were completed. The record lacked a reason why the task was not completed. On 08/27/2025, the Director of Nursing, acknowledged the aides did not follow the aide plan of care and although the electronic medical record allows documentation of the reason for not performing the task, she agreed no reasons was documented.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the aide reported 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. CLINICAL RECORD 11: The aide plan of care, dated 07/14/2025, included visit frequencies of 3 times per week, and the following tasks to be completed each visit: hair care, skin care, and oral care. The hospice aide visit on 08/18/2025 did not document the assigned tasks of hair care, skin care, or oral care were completed. The record lacked documentation that the registered nurse (RN) was notified the plan of care tasks were not completed. CLINICAL RECORD 12: The aide plan of care, dated 05/19/2025, included visit frequencies of 5 times per week, and the following task to be completed each visit: obtain weight. The hospice aide visit notes for 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 did not document assigned task of weight every visit was completed. The record lacked documentation that the RN was notified the plan of care tasks were not completed. CLINICAL RECORD 14: The aide plan of care, dated 08/01/2025, included visit frequencies of 3 times per week, and the following task to be completed each visit: hair care, skin care, foot care, oral care, elimination and home management. The hospice aide visit note dated 08/20/2025 did not document that the assigned tasks of hair care, skin care, foot care, oral care, elimination or home management were completed. The record lacked documentation that the RN was notified the plan of care tasks were not completed. On 08/27/2025, the Director of Nursing, confirmed the records did not include documentation that the aides notified a RN when the plan of care was not followed.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services. This standard was not met as evidenced by document review, interview, and personnel record review. In 3 of 9 (33%) personnel record reviewed for individuals who are providing care, the agency did not ensure the staff were assessed for skills and competencies prior to caring of patients, in accordance with agency policy. Agency Policy 3.8, Competency Assessment (no date) stated in part, “As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing unsupervised care.” Additionally, “competency evaluations are carried out by professional that have appropriate supervisory experience in the area of expertise of the person being evaluated (i.e., an Medical Social Worker (MSW) will perform competency exam on an MSW).” PERSONNEL RECORD 1: The Registered Nurse (RN) was hired on 12/30/2024. The document titled, “Competency Skills Checklist Registered Nurse” lacked a date completed and each individual skill evaluated lack preceptor’s initials and dates. The RN completed orientation and was assigned care of patients without documented evidence of when the competency was completed. PERSONNEL RECORD 3: The Medical Social Worker (MSW) was hired on 09/23/2024. The document titled, “Competency Skills Checklist for Medical Social Worker” was completed by the Director of Nursing-Registered Nurse. As per agency policy, the evaluation must be conducted by an MSW. PERSONNEL RECORD 8: The Bereavement Coordinator was hired on 03/03/2025. The document titled, “Competency Skills Checklist for Bereavement Coordinator” was not completed. During an interview on 08/26/2025 with the Director of Nursing confirmed the competency skills checklist for Personnel Record 1 was incomplete and could not verify completion prior to assignment of patient care, Personnel Record 3 was completed by the Director of Nursing, and she stated she was unaware of the policy and procedure verbiage related to who could perform the evaluation, Personnel Record 8 she stated that no competency evaluation could be located in the personnel record.”