Every finding on record at Jol Hospice Kyle, LLC

Based on record review and interview the agency failed to ensure home health aide visits or missed visit notes were documented in each patient record as applicable for 3 of 19 sampled patients (Patient #9, #11 and #13). Failure to document all patient visits or missed visits had the potential to cause harm in that valuable patient information would not be available to interdisciplinary team members and patient needs may not have been met. --- Findings include: Review of the clinical record for Patient #9 revealed a start of care date of 05/08/2025 with a diagnosis of Multiple Myeloma. Multiple Myeloma is a form of cancer of the blood. Review of the plan of care for the period 05/08/2025-07/04/2025 revealed orders: HHA services 3 times per week for 12 weeks, then 1 time per week for 1 week. Review of the clinical record for the week of 06/15/2025-06/21/2025 revealed documentation that HHA services were provided 1 time on 06/18/2025. Review of visit notes revealed no documentation of additional HHA visits or missed visits during that week. Review of the clinical record for Patient #11 revealed a start of care date of 08/23/2023 with a diagnosis of Multiple Sclerosis. This disease causes severe muscle weakness. Review of the plan of care for the period 04/14/2025-6/12/2025 revealed orders: HHA services 2 times per week for 8 weeks, then 1 time per week for 1 week. Review of the clinical record for the week of 05/04/2025-05/10/2025 revealed HHA services were provided 1 time 05/06/2025. During the week of 06/01/2025-06/07/2025 revealed HHA services were provided 1 time on 06/03/2025. Review of visit notes revealed no documentation of additional HHA visits or missed visits during those weeks. Review of the clinical record for Patient #13 revealed a start of care date of 03/28/2025 with a diagnosis of colon cancer. Review of the plan of care for the period 03/28/2025-05/24/2025 revealed orders: HHA services 2 times per week for 12 weeks, then 1 time per week for 1 week. HHA services were discontinued on 05/06/2025. During the period 04/13/2025-05/06/2025 no HHA visits were documented. Documentation of one HHA missed visit on 04/17/2025 was noted. An Interview was conducted on 07/16/2025 at 2:35 PM with A/ASN and AA/SN. The clinical records for Patients #9, #11 and #13 were reviewed and documentation of additional visits or missed visits were requested for review. AA/SN stated there were some glitches in the electronic medical records software that may have caused issues with documentation. A/ASN stated the agency would contact the customer support department to address the issues. Both administrators acknowledged the lack of documentation of visits or missed visits. Surveyor asked if it was known if HHA services were provided as ordered. A/ASN and AA/SN advised they would review the visit records and provide additional information if any was uncovered. No additional information was available by the time of exit.Review of the agency’s policy and procedure manual revealed a policy titled “Medical Record Content, IM.30, Last Reviewed:090124” which read, “The content of the medical record will include, at a minimum, Clinical notes documenting functional and activity limitations, all actions, interventions, and procedures provided by the hospice, including medication administration, treatments, and services, and the responses to interventions.”

Based on record review and interview, the agency failed to ensure an on-site visit to a patients home to supervise hospice aide services was completed at least every 14 days. This failure resulted in the quality of hospice aide services provided for two of five clients whose records were reviewed (Patients #1 and #2) not being monitored and has the potential to result in substandard care being provided or care not being followed as ordered by the hospice IDT. Findings: Review of the clinical record of Patient #1 revealed a POC dated 7/13/2023 to 10/19/2023 which read in part: HHA (Hospice Aide) effective 7/13/2023- 2wk 12 (2 times a week for 12 weeks). Review of the clinical record for Patient #1 for the period of 7/13/2023 to 9/9/2023 revealed hospice aide services were provided on 7/17/2023, 7/20/2023, 7/25/2023, 7/27/2023, 8/1/2023, 8/3/2023, 8/8/2023, 8/10/2023, 8/15/2023, 8/17/2023, 8/22/2023, 8/24/2023, 8/29/2023, 8/31/2023, 9/3/2023 and 9/7/2023. Review of the clinical record for Patient #1 revealed HHA supervisory visits were completed by a RN on 8/15/2023, 8/24/2023 and 9/6/2023. The period from 7/17/2023 (when HHA services were initiated) to 8/15/2023 (first HHA supervisory visit) is 29 days. Review of RN visit notes dated 7/18/2023, 8/1/2023 and 8/8/2023 did not contain documentation that a supervisory visit was completed by the RN during the visits for the HHA. Visit note dated 7/18/2023 read in part: ";Were supervisory functions performed? NO, Indicate reason supervisory functions not performed: Not Applicable to todays visit." Visit notes dated 8/1/2023 and 8/8/2023 contained a supervisory function for the LVN, but not the HHA. Review of the clinical record of Patient #2 revealed a POC dated 5/31/2023 to 8/28/2023 which read in part: HHA (Hospice Aide)- 1wk1 (1 time a week for 1 week), 2wk 12 (2 times a week for 12 weeks). Review of the clinical record for Patient #2 for the period of 5/31/2023 to 7/29/2023 revealed hospice aide services were provided on 6/2/2023, 6/6/2023, 6/8/2023, 6/13/2023, 6/15/2023, 6/20/2023, 6/22/2023, 6/27/2023, 6/29/2023, 7/4/2023, 7/6/2023, 7/10/2023, 7/13/2023, 7/18/2023, 7/20/2023, 7/24/2023 and 7/27/2023. Review of the clinical record for Patient #2 revealed no HHA supervisory visits were documented during this time frame. Review of RN visit notes dated 6/6/2023, 6/8/20203, 6/15/2023, 6/20/2023, 6/26/2023, 7/11/2023 and 7/18/2023 did not contain documentation that a supervisory visit was completed by the RN during the visits. Visits Notes dated 6/6/2023, 6/8/2023, 6/15/2023, 6/20/2023, 6/26/2023 and 7/18/2023 read in part: ";Were supervisory functions performed? NO, Indicate reason supervisory functions not performed: Not Applicable to todays visit." Visit note 7/11/2023 contained a supervisory function for the LVN, but not the HHA. During an interview with the Administrator on 9/27/2023 at 9:51 am, the Administrator stated she did not see any additional HHA supervisory visits completed for the aide of Patient #1. During an interview with the Administrator on 9/27/2023 at 10:20 am, the Administrator stated she did not see any HHA supervisory visits for the aide of Patient #2 for the reviewed time frame. The Administrator stated, ";if they were not documented, they were not done." During an interview with RN on 9/28/2023 at 11:10 am, RN stated she was aware that the supervisory visits needed to be done every 14 days. RN stated she does not know why she missed the visits, and stated ";I have no explanation, I cannot justify why it was not done." RN stated she usually does HHA supervisory visits every week.