Every finding on record at Brio Idaho Hospice LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records review, the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit dated 07/31/2023, with a terminal diagnosis of breast cancer. The clinical record contained no documented evidence that an initial bereavement assessment was completed. During an interview dated 08/21/23, the Hospice Director stated the pre bereavement assessment was usually completed by the social worker and it was rare that the social worker was not accepted, that was how it was missed. Also, the software was designed so that the assessment had to be pulled separately and only the social workers were really oriented to do this but that will now be corrected.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the agency did not ensure that the plan of care identified planned interventions individualized to the patient's condition. Clinical Record 4: The patient elected the hospice benefit dated 08/04/2023, with a terminal diagnosis of pancreatic cancer. Clinical record review revealed the patient had a foley catheter attached to a large drainage bag and the catheter was due to be changed 09/27/2023. The plan of care dated 08/04/2023 through 10/02/2023 did not include interventions for care of the foley catheter and did not include an order for the size of the catheter or balloon volume to be used when the catheter is changed on 09/27/2023. Clinical Record 5: The patient elected the hospice benefit dated 08/01/2023, with a terminal diagnosis of acute/chronic congestive heart failure. The hospice plan of care dated 08/01/2023 included an intervention that stated, “Ostomy Care to Include” and was left blank. Review of the clinical record revealed the patient does not have an ostomy. During an interview dated 08/22/2023, the Hospice Director stated that a new quality review team has been hired as this was a recognized problem and they are working on a process improvement for these items.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed in which the hospice aide was accepted, the agency did not ensure tasks assigned to the aide were clear and specific. Clinical Record 2: The patient elected the hospice benefit dated 08/05/2023, with a terminal diagnosis of Alzheimer’s disease. The aide plan of care assignment created by the Registered Nurse (RN) dated 08/05/2023 assigned task stated, "Apply barrier cream to (blank line).” The aide task assignment did not include the location or specific instructions for application. Clinical record review revealed oxygen had been ordered for the patient dated 08/09/2023, oxygen was not added to the aide plan of care assignment. Clinical Record 5: The patient elected the hospice benefit dated 08/01/2023, with a terminal diagnosis of acute/chronic congestive heart failure. The aide plan of care assignment created by the RN dated 08/01/2023 assigned task stated, "Obtain Pulse, Respirations, Blood pressure and Temperature,” and in the instruction for each task the criteria / parameters to report to the RN were blank. The aide plan of care assignment for obtaining the patient’s vital signs did not include instructions on when to report vital sign values to the RN. During an interview dated 08/22/2023, the Hospice Director stated that the aides do not take vital signs but agrees that the plans of care did not have accurate directions for the aide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed in which the hospice aide was accepted, the agency did not ensure that the aide documented all tasks that were ordered on the plan of care assignment. Clinical Record 5: The patient elected the hospice benefit dated 08/01/2023, with a terminal diagnosis of acute/chronic congestive heart failure. The aide plan of care assignment created by the Registered Nurse dated 08/01/2023 assigned task stated, "Obtain Pulse, Respirations, Blood Pressure and Temperature" each visit. Review of aide visit notes dated 08/08/2023, 08/10/2023 and 08/15/2023 revealed the aide documented a temperature at each visit but did not document blood pressure, pulse or respirations and did not document a reason for not taking these assigned tasks. During an interview dated 08/22/2023, the Hospice Director stated that the aides should not have been assigned the task of obtaining vital signs but agreed that the plan was not updated, and the documented tasks did not match the plan of care.

It is required that volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed that documented acceptance of a volunteer, the agency did not ensure volunteer services were provided to the patient and documented in the clinical record. Clinical Record 2: The patient elected the hospice benefit dated 08/05/2023, with a terminal diagnosis of Alzheimer’s disease. Review of the nursing assessment dated 08/05/2023 and the plan of care dated 08/05/2023 through 11/02/2023 revealed documentation that the patient had accepted volunteer services. As of the date of clinical record review on 08/21/2023, there was no documented evidence in the clinical record that volunteer services had been provided to the patient and no documented reason why the volunteer had not seen the patient. During an interview dated 08/21/2023, the Hospice Director stated the volunteer coordinator recently resigned and this was missed but that a call had been made that day with the family to follow up with a volunteer.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: Current subjective and objective medical findings. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (84%) clinical records review, the agency did not ensure that the certification of terminal illness (CTI) included evidence that the physician considered the patient’s current subjective and objective medical findings to evaluate hospice qualifications. Clinical Record 1: The patient elected the hospice benefit dated 07/31/2023, with a terminal diagnosis of breast cancer. The CTI documented by the physician stated, “Metastatic Breast CA [cancer] and is experiencing significant decline and is hospice appropriate." The CTI lacked documentation of current subjective and objective medical findings to support that the patient was evaluated to determine a six month or less life expectancy. The Registered Nurse documented on the initial comprehensive assessment the patient was scored at a 40% Karnofsky [Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment with 100% being normal health]. The patient was sleeping more during the day, which was a new finding. The patient/caregiver reported recent weight loss, but patient refused weight, and the patient eats 25-50% of food instead of 100%. The son reported the patient was experiencing increased anxiety and angry outbursts with poor communication and was refusing medications to assist with pain and nausea. Clinical Record 2: The patient elected the hospice benefit dated 08/05/2023, with a terminal diagnosis of Alzheimer’s disease. The CTI documented by the physician stated, “severe Alzheimer's and atrial fibrillation and is hospice appropriate." The CTI lacked documentation of current subjective and objective medical findings to support that the patient was evaluated to determine a six month or less life expectancy. The Registered Nurse documented on the initial comprehensive assessment the patient was scored at a 40% Karnofsky, the patient was confused with new aggressive behavior reported by daughter. The nurse also documented the patient is no longer ambulatory and required a two person assist to wheelchair and is no longer able to live alone and now requires 24-hour care. Clinical Record 3: The patient elected the hospice benefit dated 07/26/2023, with a terminal diagnosis of ovarian cancer. The CTI documented by the physician stated, “metastatic ovarian cancer with significant ascites and remains hospice appropriate." The CTI lacked documentation of current subjective and objective medical findings to support that the patient was evaluated to determine a six month or less life expectancy. The Registered Nurse documented an assessment that stated the patient had declined since April 2023 with increased edema, acid reflux which causes pain and a drainage tube for the ascites which causes discomfort and requires daily draining with an amount that was frequently over 2 Liters. Clinical Record 4: The patient elected the hospice benefit dated 08/04/2023, with a terminal diagnosis of pancreatic cancer. The CTI documented by the physician stated, “she had terminal cancer and is declining and hospice appropriate." The CTI lacked documentation of current subjective and objective medical findings to support that the patient was evaluated to determine a six month or less life expectancy. The Registered Nurse documented an assessment that stated the patient was scored at a 50% Karnofsky and 50% PPS [Palliative Performance Scale]. The nurse also documented the patient has had increased pain in the last couple of months, decreased appetite and has a foley catheter in place. Clinical Record 5: The patient elected the hospice benefit dated 08/01/2023, with a terminal diagnosis of acute/chronic congestive heart failure. The CTI documented by the physician stated, “patient has worsening CHF (congestive heart failure) and is hospice appropriate." The CTI lacked documentation of current subjective and objective medical findings to support that the patient was evaluated to determine a six month or less life expectancy. The Registered Nurse documented an assessment that stated the patient was scored at a 60% Karnofsky and a 60% PPS. The nurse also documented the patient experienced increased shortness of breath with minimal activity, increased muscle wasting and increased pain. During an interview dated 08/21/2023, the Hospice Director stated that the medical director did not want to document something that he had not actually observed but now understands that he can reference the nursing assessment and referral documentation to help certify the terminal illness.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents review, Governing Body Meeting Minutes review and interviews with the Director of Nursing, Assistant Director of Nursing and the Administrator/QAPI Coordinator, which revealed issues with the CQI program in the following areas: Failed to measure, analyze, and track quality indicators, including adverse patient events, that enable the hospice to assess processes of care, hospice services, operations, and adverse events [HQPI.4.I/L562]; Failed to use quality indicator data, including patient care data and other relevant data, to monitor the effectiveness and safety of services and quality of care [HQPI.5.I/L564]; Failed to track adverse patient events, analyze their causes, and implement preventive actions [HQPI.7.I/L569]; Failed to take action to improve performance and to track performance to ensure improvements were sustained [HQPI.8.I/L570]; and Failed to document performance improvement projects undertaken, the reasons for conducting the projects, and the measurable progress achieved [HQPI.9.I/L573]. The cumulative effect and scope of these deficiencies could negatively impact the organization's ability to provide safe and effective patient care and services, and to evaluate the provision of services to determine areas in need of improvement. This condition was not met as evidenced by a review of quality meeting minutes and interviews of the management team, which revealed that the hospice failed to demonstrate measurable improvement in indicators related to improved palliative outcomes and hospice services [HQPI.3.I/418.58(a)(1)/L561]; to measure, analyze, and track quality indicators of performance that enable the assessment of processes of care; hospice services; operations; and adverse events [HQPI.4.I/418.58(a)(2)/L562]; failed to use data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement [HQPI.5.I/418.58(b)(2)(i)/L564]; failed to document number and scope of performance improvement projects conducted annually to represent the needs of the hospice population served, represent the internal needs of the organization, and reflect the scope, complexity, and past performance of the hospice’s services and operations. [HQPI.6.I/418.58(c)(1)(iii)/L-568]; failed to have affect palliative outcomes, patient safety, and quality of care. [HQPI.7.I/418.58(c)(2) (2)/L-569] failed to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice. [HQPI.8.I/418.58(c)(3)(3)/L-570] failed to implement those actions, measure its success, and track performance to ensure that improvements are sustained.

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse events. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure the measurement, analysis, and tracking of infection control issues/adverse events, and quality indicators related to the COVID-19 Public Health Emergency (PHE) to assess processes of care, hospice services and operations. The organizational policy, "Quality Assessment and Performance Improvement (QAPI) Plan", stated in part, “…Home Health [hospice] must measure, analyze, and track quality indicators including adverse events and other aspects of performance that enable [hospice] agency to assess processes of care, services, and operations. The program must utilize quality indicator data, including measures derived from OASIS and other relevant data in the design of its program. Performance improvement activities must track adverse events, analyze their causes and implement preventative actions. …The Governing Body ensures that all improvement actions are evaluated for effectiveness. …The QAPI committee will be responsible for coordinating all QAPI activities, reviewing the collection of data, analyzing data, and assisting staff in developing improvement activities, planning actions, collecting data and analyzing the effectiveness of actions, and implementing effective actions...Sources of information from which data may be collected include (but are not limited to): Measures derived from OASIS data (when applicable), adverse event reports, home visits, patient medical records, patient/caregiver interviews, staff interviews, policies/procedures, incident reports, medication profiles, on-call logs, supervisory visit observations, peer review, patient perception of care surveys, recommendations from federal, state, and accreditation surveys and other regulatory agencies. " The Administrator (and Governing Body appointed QAPI Coordinator) confirmed the organization had access to quality indicators and measures listed in the organization's QAPI policy, including data related to adverse patient events, but the organization had not tracked or analyzed any of the quality data listed in the policy as a part of the organization's QAPI activities during the years of 2021, 2022, or the first half of 2023. The Administrator was unable to produce documentation that evidenced measurement, analysis and tracking of quality data/indicators related to infection control/adverse events and the PHE. During an interview on 7/13/23, the DON stated, "We do have quality indicator data that we have access to and we can provide it to you for you to review. No, we have not tracked or analyzed this data to know the percentages of achievement of any quality indicators." The organizational policy titled Quality Assessment and Performance Improvement (QAPI) Plan states in part, "...The program must utilize quality indicator data, including measures derived from OASIS and other relevant data in the design of its program. ..." Binder titled QAPI Home Health & Hospice does not include any quality indicator data from OASIS assessments or HHCAHPS patient satisfaction survey results for 2021, 2022, or the First quarter of 2023. During an interview with the DON, ADON, and Administrator on 7/13/23, the DON stated, "We have access to all of that data and can pull it for you. We've won awards for our high patient satisfaction results." When asked if this data was utilized in the QAPI program, the Administrator (who is also appointed as the QAPI Coordinator by the Governing Body) stated, "No we do not incorporate OASIS or patient satisfaction survey results into our QAPI."

It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data collected is used to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interview. The organizational policy titled Quality Assessment and Performance Improvement (QAPI) Plan states in part, "...The program must utilize quality indicator data...and other relevant data in the design of its program. ..." Binder titled QAPI Home Health & Hospice did not include any quality indicator data for 2021, 2022, or the First Quarter of 2023. A review of Governing Body Meeting minutes dated 3/1/2021, 8/5/2021, 8/19/2021, 9/23/2021, 12/23/2021, 3/21/2021 6/9/2022, 9/22/2022, and 3/2/2023 revealed no evidence that agency's governance approved the frequency and detail of data collection for the agency QAPI program. During an interview with the DON, ADON, and Administrator on 7/13/23, the DON stated, "We have access to all of that data and can pull it for you. We've won awards for our high patient satisfaction results." When asked if this data was utilized in the QAPI program, the Administrator (who is also appointed as the QAPI Coordinator by the Governing Body) stated, "No we didn't use HCAPHS or HIS to review." It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. The frequency and detail of the data collection are approved by the hospice’s governance. This standard was not met, as evidenced by a review of QAPI meeting minutes, Agency Policy, and Performance Improvement Projects (PIP). The Agency Policy and Procedure #11.7.1 titled, "Record Review" states in part, "regularly, a random sampling of active and discharged patient records will be selected for review . . . the results of the review will be presented to the Governing Body and appropriate Hospice staff". Agency documentation lacked evidence of regularly sampling. The agency produced documentation of PIPs, all written in 2023. However, the PIPs lacked evidence of quality indicator data and abstracted and aggregated data from comprehensive patient assessments to include a random sampling of active and discharged patient records. Agency could not confirm the utilization of outside aggregate reporting for defined data detail.

It is required that performance improvement activities track adverse patient events, analyze the causes and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met, as evidenced by a review of quality meeting minutes and interviews of the management team on 7/13/23, which revealed that the hospice failed to track patient adverse events, analyze the data that was collected, and show measurable improvement in indicators related to improved palliative outcomes and hospice services. The organizational policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan", stated in part," …must take actions aimed at performance improvement and, after implementing actions, must measure its success and track performance to ensure that improvements are sustained. …The Governing Body ensures that all improvement actions are evaluated for effectiveness. …The QAPI committee will be responsible for coordinating all QAPI activities, reviewing the collection of data, analyzing data, and assisting staff in developing improvement activities, planning actions, and collecting data and analyzing the effectiveness of action and implementing effective actions." There was no evidence that adverse patient events were tracked and analyzed to determine causes. There was no evidence that preventive actions were implemented related to adverse events. that included feedback and learning throughout the hospice. There was no performance improvement activity presented which addressed palliative outcomes, patient safety, and quality of care. The Administrator/QAPI Coordinator reiterated that quality indicators as defined by the organizational policy were not documented at a baseline or tracked or analyzed in writing for the organization to be able to ensure improvements in 2021, 2022, or the first two quarters of 2023. This standard was not met, as evidenced by a review of quality meeting minutes and interviews of the management team on 7/13/23, which revealed that the hospice failed to track patient adverse events, analyze the data that was collected, and show measurable improvement in indicators related to improved palliative outcomes and hospice services.

It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it, and tracks ongoing results to ensure improvement is sustained. This standard was not met as evidenced by document review and interview. The agency failed to document the assessment of the success of the action they would take to improve performance and track the ongoing results to show whether their implementation was successful or not. The administrator stated they identified the problems and discussed the performance improvement projects but did not document the discussion or results. The agency failed to document the assessment of the success of the action they would take to improve performance and track the ongoing results to show whether their implementation was successful or not. The administrator stated they identified the problems and discussed the performance improvement projects but did not document the discussion or results.

It is required that the organization documents the performance improvement projects undertaken, the reasons for conducting these initiatives, and the measurable progress achieved on these projects. This standard was not met as evidenced by document review and interview. The organizational policy titled Quality Assessment and Performance Improvement (QAPI) Plan, stated in part,"… “…A summary of data collection, analysis, and recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee. The reports are forwarded to the Governing body. ..." The agency produced documentation greater than five (5) Performance Improvement Projects (PIPs) written July 7, 2023, the week prior to the site visit. The DON and Administrator/QAPI Coordinator confirmed that the PIPS were not based on analysis of any performance improvement activities that were conducted in the past as there was no documented PIP activities in 2020 or 2021. The Administrator/QAPI Coordinator confirmed that a documented summary of projects undertaken and the reasons for conducting these initiatives including data collection, analysis and recommendations for improvement along with a report of cumulative findings as required by organizational policy was not documented by the QAPI committee or the QAPI Coordinator in 2021, 2022, or through the first half of 2023.

It is required that licensed professionals participate in hospice-sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. 4 of 6 (67%) records reviewed of licensed professionals revealed the agency did not ensure they employees and contract staff had ongoing hospice in-services. Personnel Record 2: The director of nursing's personnel record and printout sheets did not show participation in ongoing in-service training since her hire date on 1/16/21. Personnel Record 3: The RNCM's personnel record and printout sheets did not show participation in ongoing in-service training after 7/13/21. Personnel Record 1: There was no evidence in the personnel record that the medical director had any hospice-sponsored in-service training in 2021, 2022, or 2023. Personnel Record 10: There was no evidence in the personnel record that the associate medical director had any hospice-sponsored in-service training in 2021, 2022, or 2023. The administrator was interviewed on 7/13/23 and stated she had just become aware last week that the employee was supposed to be responsible for completing the HR records. They implemented a PIP but haven't had time to correct the problem.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 6 of 8 (75%) clinical records reviewed with aide services revealed the agency did not ensure the aide reported changes in the care plan or missed visits to the registered nurse. Clinical Record 1: Aide services were started on 5/22/23 for 3 times a week. The aide missed visits on 6/7/2023, 6/12/23, and 7/3/23. There was no documentation from the aide that the registered nurse was notified of these missed visits and such changes which related to the plan of care. Clinical Record 2: Aide services were started on 5/19/23. Aide noted on 5/19/23 that she could not complete the tasks of showering with a chair and washing (his) hair, and on 6/28/23, she did not change the linens as was on the aide care plan. On 5/29/23, the aide had a missed visit for the holiday. There was no documentation from the aide that the registered nurse was notified of this missed visit and such changes which related to the plan of care. Clinical Record 3: Aide had visits scheduled on 7/3/23 and 7/5/23 and missed the visits per the patient's request. There was no documentation that the aide informed the registered nurse of the missed visits nor documentation of the approval from the registered nurse. Clinical Record 4: Aide visits were scheduled for 2 times a week starting 7/2/23. There were missed visits on 7/4/23 and 7/11/23 per the patient's request. There was no documented report to the registered nurse about the missed visits. Clinical Record 5: Aide was scheduled to see the patient on 7/3/23 for a routine visit and canceled the visit per clinician without any documentation that the aide notified the registered nurse of the missed visit. Clinical Record 8: Aide had visits scheduled for 2 times a week starting 7/5/23. Aide was scheduled to see the patient on 7/5/23, 7/7/23, and 7/11/23 and missed the visits per the client's request. There was no documented report to the registered nurse about the missed visits. Personnel Record 2: The director of nursing was interviewed on 7/12/2023 and agreed there was no documentation in the clinical record notes the registered nurse had been notified of the changes from the aide plan of care and missed visits.

It is required that the hospice provides an initial orientation for each employee that addresses infection control and organization procedures and policies and procedures on advance directives, and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. 3 of 10 (30%) personnel records reviewed revealed the agency did not ensure the employee received initial orientation on infection control and education on policies and procedures. Personnel Record 2: The director of nursing was hired on 1/16/2021. There was no initial orientation documentation found in her personnel records. Personnel Record 4: The Aide was hired on 9/20/2021. There was no initial orientation documentation found in her personnel records. Personnel Record 7: The volunteer coordinator was hired on 1/17/2021. There was no initial orientation documentation found in her personnel records. The administrator was interviewed on 7/13/2023 and agreed there was no orientation documentation for the director of nursing, aide, and volunteer coordinator in the personnel records.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, and the needs and concerns of patients and families coping with a terminal illness. This standard was not met as evidenced by interview and personnel record review. 3 of 10 (30%) personnel record reviewed revealed the agency did not ensure the employees were provided orientation on each employee's specific job duties. Personnel Record 2: The director of nursing was hired on 1/16/2021. There was no initial orientation documentation that addressed the employee's specific job duties found in her personnel records. Personnel Record 7: The volunteer coordinator was hired on 1/17/2021. There was no initial orientation documentation that addressed the employee's specific job duties found in her personnel records. Personnel Record 4: The Aide was hired on 9/20/2021. There was no initial orientation documentation that addressed the employee's specific job duties found in her personnel records. The administrator was interviewed on 7/13/2023 and agreed there was no orientation documentation for the director of nursing, aide, and volunteer coordinator in the personnel records.