Every finding on record at Affinity Care of Pennsylvania LLC

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #7006, "Competency Assessment Policy" (dated 2019), stated in part, "A competency assessment will be completed at least 1 time per year... The agency will use a competency skills performance checklist developed specifically for each clinical job category...the clinical manager will evaluate the competence in performing and rendering care according to organization policies." In 1 of 1 (100%) personnel record reviewed of a Hospice Aide who required an annual on-site visit, the agency did not ensure that the Registered Nurse (RN) made an annual on-site visit to observe and assess the Hospice Aide (HA) while the HA performed care. Personnel Record 8: The HA was hired on 06/08/2022. A personnel record review revealed an initial competency done upon hire. There was no documentation of an annual on-site visit by the RN in 2023 and 2024 to observe and assess the HA while performing care. During a joint review of the personnel files on 03/18/2025, the Regional Director confirmed there was no annual on-site visit documented with the RN to observe the HA for 2023 and 2024.

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 document review, interview, and personnel record review. Agency policy #7006, "Competency Assessment Policy" (dated 2019), stated in part, "A competency assessment will be completed at least 1 time per year... The agency will use a competency skills performance checklist developed specifically for each clinical job category...the clinical manager will evaluate the competence in performing and rendering care according to organization policies." In 2 of 6 (40%) personnel records reviewed of individuals providing care who require an annual competency evaluation, the agency did not ensure that annual competencies were performed as required per policy. Personnel Record 4: The Social Worker (SW) was hired on 09/26/2023. A personnel record review revealed a SW competency at hire in 2023. There was no documentation of an annual competency assessment for 2024. Personnel Record 9: The Chaplain was hired on 08/04/2022.A personnel record review revealed a Chaplain competency at hire in 2022. There was no documentation of an annual competency assessment for 2023 or 2024. During a joint review of personnel files on 03/17/2025, the Regional Executive Director confirmed that annual competencies were missing from personnel records 4 and 9. The Executive Director reviewed the policy and agreed that the agency should have performed an annual competency for those employees.