Every finding on record at Living Light LLC

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 5 (20%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the aide provided services that were included in the plan of care. CLINICAL RECORD 2/Home Visit 2: The aide care plan dated 01/16/2025 ordered: "clean nails.” During the home visit with the Hospice Aide (Personnel Record 6) on 02/04/2025, the aide was observed in filing the nails after the patient had taken a shower. The aide plan of care did not instruct the aide to file the nails. During an interview, on 02/04/2025, the Administrator stated, "more education will be provided to aide to only do what is on the plan of care."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that aide supervisory visits were documented no less frequently than every 14 days. CLINICAL RECORD 1: The record was reviewed for aide supervisory visits between the initial nursing assessment dated 09/15/2024 through 02/05/2025. The aide had a frequency order of two (2) times per week. There was evidence of aide supervisory visits completed on: 09/30/2024; 10/08/2024; 10/22/2024; 11/13/2024; 11/18/2024; 11/25/2024; 12/08/2024; 12/27/2024 (which was 19 days); 01/08/2025; 01/17/2025; and 01/29/2025. The record lacked evidence of aide supervisory visits no less frequently than every 14 days. CLINICAL RECORD 3: The record was reviewed for aide supervisory visits between the initial nursing assessment dated 09/29/2024 through 02/05/2025. The aide had a frequency order of two (2) times per week. There was evidence of aide supervisory visits completed on: 10/13/2024; 10/23/2024; 11/12/2024 (which is 20 days); 11/26/2024; 12/02/2024; 12/27/2024 (which was 25 days); 01/11/2025 (which was 15 days); 01/17/2025; and 01/21/2025. The record lacked evidence of aide supervisory visits no less frequently than every 14 days. CLINICAL RECORD 6: The record was reviewed for aide supervisory visits between the initial nursing assessment dated 09/19/2024 through 01/15/2025. The aide had a frequency order of two (2) times per week. There was evidence of aide supervisory visits completed on: 10/02/2024; 10/17/2034 (which was 15 days); 10/29/2024; 11/13/2024 (which was 15 days); 11/18/2024; 12/02/2024; 12/13/2024; 12/20/2024; and 01/02/2025. The record lacked evidence of aide supervisory visits no less frequently than every 14 days. During an interview on 02/05/2025, the Administrator verified that the records lacked evidence of the aide supervisory visits being conducted at least every 14 days. She stated, "We will do more education with our clinicians."