Every finding on record at Rocky Mountain Hospice of Billings, LLC

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, personnel record review, and interview. Agency policy #HOS-C_12 "Evaluation of Clinical Competency for Hospice Licensed Professionals and Hospice Aides" (effective 04/07/2021) (revised 04/17/2025) stated in part, "Procedure. 3. For Hospice Aides -A SKILLS evaluation using the competency worksheet designed for hospice aides is required at the time of hire and annually. Steps for completion. 1. Those skills requiring direct observation must be performed with a patient or a pseudo-patient. 3. Use the skills checklist and the hospice aide assignment to inform the colleague of the desired skills to be performed. 4. Observe the aide during the provision of care and note on the skills checklist. 5. Once the aide has completed all required tasks, the registered nurse and aide sign off on the form and date it to indicate the process is complete." In 1 of 1 (100%) personnel records reviewed of a Hospice Aide (HA), the agency did not ensure that the Registered Nurse (RN) conducted an annual on-site visit to the location where a patient was receiving care to observe and assess the Hospice Aide (HA) performing care. Personnel Record 7: A review of the personnel file for the Hospice Aide hired on 08/01/2022 revealed that the 2023 "annual on-site visit" did not contain documentation of skills being evaluated. The column labeled "patient/pseudo patient" was not filled out. The section of the form designated for the RN's signature included the RN's first name, no credentials, and had a line drawn down to the bottom. The form did not document that this was an onsite visit. During a joint clinical record review and interview conducted on 07/24/2025, the Director of Clinical Services stated, "This was not filled out per policy, and this was an issue with the previous leadership that we have worked on correcting since."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview with the Volunteer Coordinator (VC) and a document review conducted on 07/23/2025 revealed that the volunteer percentage for the past year (June 2024 to June 2025) in either an administrative or patient care role was calculated at 4.22%. The Volunteer Coordinator, who has been in the VC role for approximately six (6) months, stated that the hospice "struggled with recruitment at first but has improved in the last two to three months." Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review were conducted with the Volunteer Coordinator on 07/23/2025, and the volunteer percentage for the past year (June 2024 to June 2025) in either an administrative or patient care role was calculated at 4.22%. The Volunteer Coordinator has been in her role for approximately six (6) months and "struggled with recruitment at first but has improved in the last two to three months."