Every finding on record at Lakes Region Visiting Nurse Association

Based on medical record review and interview, it was determined that the agency failed to supervise the quality of care and services provided by hospice aides no less frequently than every 14 days for 1 of 14 patients reviewed for hospice aides in a survey sample of 19 patients (Patient Identifier #16). --- Findings include: Review on 2/14/24 of Patient #16's hospice aide visits revealed the following visit dates: 12/19/24, 12/22/24, 12/26/24, 1/5/24, and 1/9/24. Review on 2/14/24 of Patient #16's nursing visit notes revealed that on-site visits by a registered nurse to assess the adequacy and care of the hospice aide services were completed on 12/15/23 and 1/9/24, revealing that 25 days had elapsed between assessments. Review also revealed that a nurse visit was completed on 12/19/23 and a telephone call was completed on 1/2/24 but no documentation evidence that hospice aide supervision had been performed. Interview on 2/14/24 at approximately 12:30 p.m. with Staff A (Director of Clinical Operations) confirmed the above findings.

Based on interview and record review it was determined that the agency failed to complete a criminal background check prior to employment for 1 out of 5 employees reviewed (Staff B). --- Findings include: Review on 2/14/24 of Staff B's (Medical Director) employee file revealed that Staff B started employment on 7/31/23. Further review of Staff B's employee file revealed that Staff B's criminal background check was completed on 8/31/23. Interview on 2/14/24 at approximately 8:45 a.m. with Staff A (Director of Clinical Operations) confirmed the above finding. Staff A revealed that Staff B was in training from 7/31/23 through 8/31/23 and did have access to patient records during his/her training.