Every finding on record at Stein Hospice Services, Inc

Based on personnel record review, staff interview, and review of agency policy, the agency failed to ensure Hospice Nurse Aide (HNA) competencies were completed prior to working independently with patients for one of four HNA personnel records reviewed (Staff D). The agency census was 114. Findings include: --- Review of Staff D's personnel record revealed the staff was hired as a Hospice Nurse Aide (HNA) on 03/27/23. Further review revealed the record was silent for evaluation of Staff D's competencies. Interview on 09/21/23 at 10:02 A.M. with Staff A revealed new staff had a 90-day evaluation, which included an evaluation of competencies. Staff A confirmed Staff D's personnel record did not include the 90-day evaluation or an evaluation of competencies. Follow up interview on 09/21/23 at 12:21 P.M. with Staff A verified Staff D did not have an evaluation of competencies. Staff A stated she checked with the team leader who indicated she was behind on her evaluations. Staff A confirmed Staff D was working independently with patients. Review of facility policy titled, "Competency/Performance Management Program," reviewed April 2021, revealed the competency/performance management program included checklists for each position to ensure that each new employee understands the duties, skills, and competencies for which the employee is responsible.

Based on medical record review, staff interview, and review of agency policy, the facility failed to ensure Hospice Nurse Aides (HNA) received Registered Nurse (RN) supervision every 14 days for three of 15 patients reviewed for HNA services (Patient #11, #12, #13). The agency census was 114. Findings include: --- 1. Review of Patient #11's Hospice Nurse Aide (HNA) plan of care revealed the patient received HNA services three times weekly. Further review of the medical record from 08/01/23 through 09/20/23 revealed no evidence of RN supervision of the HNA. 2. Review of Patient #12's HNA plan of care revealed the patient received HNA services two times weekly. Further review of the medical record from 07/07/23 through 09/20/23 revealed only one RN supervision visit, dated 08/25/23, was completed. 3. Review of Patient #13's HNA plan of care revealed the patient received HNA services three times weekly. Further review of the medical record revealed from 08/02/23 through 09/21/23 revealed no evidence of RN supervision of the HNA. Interview on 09/21/23 at 12:24 P.M. with Staff B confirmed HNA supervision was to be completed by an RN every 14 days. Staff B verified there was no evidence of HNA supervision for Patient #11 and #13 and only one RN supervision visit was documented for Patient #12. Review of agency policy titled, "Visit Frequency," reviewed June 2023, revealed HNA supervision included no less than 15 days at an in-person RN routine/comprehensive visit, patient/family are asked about satisfaction of services. Documentation will be done on the initial and comprehensive form under HNA supervision data element.