Every finding on record at Athc - Hospice, 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 #1-036.1 "Hospice Aide Training" (dated 05/11/2020), read in part, "Annual performance reviews...will include on-site skills assessments for supervisory visits done annually..." In 1 of 1 (100%) personnel record review of a Hospice Aide, the agency did not ensure that the Registered Nurse made an annual onsite visit to the location where the patient was receiving care to observe the aide performing care. Personnel Record 9: The Hospice Aide was hired on 09/12/2016. A personnel record review on 05/29/2025 revealed no evidence of an annual on-site skills assessment supervisory visit for 2023. During a joint clinical record review and interview on 05/30/2025, the Regional Director of Clinical Operations/Acting Director of Clinical Services and Administrator confirmed there was no documentation found in the clinical records of the Registered Nurse performing aide supervision while the aide was present. During an interview on 05/29/2025, the Regional Director of Human Relations confirmed that the only annual documentation located in the personnel record for the Hospice Aide (HA) for 2023 was the Annual Performance Review and the "Annual Competency Skills Checklist Review," which only included the attestation statement, "This is to certify that I, (name), have reviewed my competency skills checklist." It was signed and dated by the HA and the RN on 08/24/2023.