Every finding on record at Aegis Home Health and Hospice LLC

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, guidance specific to individual responsibilities. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed for volunteer, the agency did not ensure documentation of volunteer orientation and training. Personnel Record 7: Volunteer/Registered Nurse date of hire 09/17/2024. Review of the personnel record revealed no documented evidence of volunteer orientation and did not include a signed job description for the role of volunteer. During an interview and record review on 03/13/2025, the Administrator and the Volunteer Coordinator confirmed that the volunteer was also a Registered Nurse and confirmed that the volunteer orientation and job description was not documented in the personnel record.

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. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. Review of agency contracts revealed the hospice did not ensure the contract included the requirement that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Review of the current Pharmacy contract revealed no documented evidence that the contract included the requirement that contracted employees who have direct patient contact or access to patient records will have criminal background checks. During an interview and review of the contract on 03/13/2025, the Director of Patient Care Services agreed the contract lacked the information and stated the agency is currently working with the pharmacy to get this added to the contract.