Every finding on record at Amaya Hospice LLC

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 1 (100%) personnel records of a hospice aide revealed that the agency did not ensure that a competency evaluation was completed by an RN prior to providing unsupervised direct patient care. Personnel Record 2: The aide was hired on 08/26/2024. CNA license effective 10/07/2003. The resume indicates continues work experience as a certified nurse aide. The agency personnel file included a competency checklist form which was blank. The self-assessment area was not completed by the employee and the evaluation of competency area was blank and not completed by a registered nurse. The employee was observed finishing personnel care at a home visit 2 (Clinical Record 2) on 08/28/2024. In review and interview with the administrator and director of clinical services on 08/28/2024, they both confirmed that the aide had not undergone a skills check evaluation prior to being assigned a patient.

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. This standard was not met as evidenced by interview and personnel record review. In 4 of 7 (57%) clinical records reviewed revealed that the agency did not ensure that all employees were assessed for skills and competency. Personnel Record 1: The registered nurse (RN) (Director of Clinical Services) date of hire was 05/01/2024. The personnel record included a skills competency checklist completed on 05/01/2024 by the alternate administrator/CFO/PT. The administrator is an RN and is the alternate director of clinical services/nursing. The alternate administrator stated on 08/28/2024, "Oh we should have had the administrator do it." Personnel Record 2: The license vocation nurse (LVN) date of hire was 05/01/2024. The Employee conducted independent visits for home visits #2 and #3. The personnel record contained a form titled "Competency Skills Checklist licensed practical/vocational nurse" and forms labeled "Pain Assessment Competency, PT/INR Machine Competency Evaluation, Competency Evaluation - Glucometer, and Personal Protective Equipment Competency Validation. All of the competency forms were blank with no evidence of review or competency evaluation from a registered nurse. Personnel Record 5: The spiritual counselor/Bereavement coordinator date of hire was 05/09/2024. The personnel record included a competency skills checklist specific for spiritual care/counselor but the checklist was blank both for the self-assessment and the evaluation and competency sections. Personnel Record 8: The Volunteer hire date was 07/15/2024 with documented volunteer activity on 08/01/2024. The personnel record contained no documented evidence of a competency assessment. In an interview with the alternate administrator and director of clinical services on 08/29/2024, they confirmed that the competency assessments were not completed prior to allowing staff to work independently.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) revoked clinical records reviewed revealed that the agency did not ensure that the hospice discharge summary was sent to the physician. Clinical Record 12: The patient was admitted on 06/24/2024 with a diagnosis of malignant neoplasm of the prostate. Note in the clinical record on 08/13/2024 revealed that the patient revoked the hospice benefit. The clinical record did not include documentation of a discharge summary and documentation that a discharge summary was sent to the physician. The administrator stated in an interview on 8/28/2024, "We spoke to the physician, but we did not send anything because they didn't ask for anything."