Every finding on record at South Coast Hospice & Palliative Care Services, Inc.

Based on review of education records for 2 Hospice Aides, review of policy and procedure and employee interview, it was determined that the agency failed to ensure that 1 Hospice Aide (Employee #2) received at least 12 hours of in-service training over a 12-month period. --- Findings: Review of the personnel file for Employee #2 revealed a hire date of 10/24/2022. The personnel file lacked documentation of in-service training during a 12-month period that included 10/24/2022 to 7/30/2024, the date of the record review. Review of the agency's policy and procedure titled "Hospice Aide Services and Training Program," with a revised date of "2014," lacked information to meet the requirement that a hospice aide must receive at least l2 hours of in-service training during each 12-month period. During an interview with the Nursing Manager and Operations Manager on 8/6/2024 beginning at 3:00 PM the findings were presented. They confirmed that the Hospice did not have the in-service record.

Based on employee education records review, policy and procedure review and interview, it was determined the Agency failed to provide documentation of initial orientation education that demonstrates the requirements of this standard are met. --- Findings: Review of 12 employee education records (Employees #1-12), revealed that 7 hospice employees (Employees #2, #3, #4, #5, #6, #8, and #9) lacked documentation to demonstrate they received initial orientation education when hired. Review of the policy titled "Employee, Volunteer and Contract Staff Infection Control Training" revealed that "Employees will receive education and training during orientation and at least annually." During interview with the Nursing Manager and Operations Manager on 8/6/2024 beginning at 3:00 PM, it was acknowledged there lacked documentation of initial orientation education for the 7 hospice employees.

Based on employee file review, policy and procedure review and interview, it was determined that the agency failed to assess the skills and competence of individuals furnishing care, and to maintain documentation of the in-service training provided during the previous 12 months. --- Findings: Review of 12 Agency employee files revealed that 9 employees (Employees #2, #3, #4, #6, #7, #9, #10, #11, and #12,) lacked documentation of competency and skill evaluation during the previous 12 months. Review of the policy titled "Hospice Aide Services and Training Program" revealed, "Documentation is maintained to demonstrate that the competency evaluation, in-service and performance review requirements are met." Review of the document titled "Infection Control Plan" revealed, "... Provide record keeping in accordance with regulations .... Monitors staff adherence to recommended policies, procedures and protective measures ... Counseling, education and/or retraining will be provided." During interview of the HR Coordinator on 7/30/2024 beginning at 2:00 PM, the above findings were discussed. The HR Coordinator acknowledged the employee files lacked competency and skill evaluations of Employees #2, #3, #4, #6, #7, #9, #10, #11, and #12.