Every finding on record at Bright Hospice Care

It is required that the supervising registered nurse assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that includes demonstrating competency with assigned tasks. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) Hospice Aide personnel records reviewed; the agency did not ensure that all aide tasks were observed by the RN before performing aide tasks independently. Personnel Record 2: This Hospice Aide was hired 04/08/2024. In review of the Performance Evaluation (Aide Competency) dated 08/30/2024, the Director of Patient Care performed the observation of tasks and documented that "baths" were observed. There was no documentation of the type of bath that was performed. In an interview with the Director of Patient Care dated 11/07/2024, it was confirmed that the Hospice Aide's ability to demonstrate all assigned aide tasks were not assessed before providing care 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%) live discharge clinical records reviewed, the agency did not ensure that a copy of the hospice discharge was sent to the patient's attending physician. Clinical Record 5: This patient was admitted 07/27/2024 for a hospice diagnosis of hypertensive heart disease with heart failure. The revocation form was signed by the patient on 07/31/2024. The clinical record contained no evidence that a discharge summary was sent to the attending physician. During an interview with the Director of Patient Care on 11/06/2024, it was stated that the discharge summary was not sent to the attending physician.

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. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by document review and interview. A review of the pharmacy contract signed 07/27/2024 revealed that the contract did not include requirements for criminal background checks on all contracted employees who have direct patient contact or access to patient records. In an interview with the Administrator on 11/08/2024, it was confirmed that the pharmacy contract did not require background checks on pharmacy employees. A review of the pharmacy contract signed 07/27/2024 revealed that the contract did not include requirements for criminal background checks on all contracted employees who have direct patient contact or access to patient records. In an interview with the Administrator on 11/08/2024, it was confirmed that the pharmacy contract did not require background checks on pharmacy employees.