Every finding on record at Visiting Nurse Association Health Group of New Jersey, LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA care plan included patient care instructions to meet the patient's needs. Clinical Record 6: The patient elected hospice care on 02/19/2025 with the diagnoses of colon cancer and lung cancer. The comprehensive assessment completed by the skilled nurse (SN) dated 02/19/2025 documented that the patient had a colostomy. The plan of care ordered HA services "2w1, 3w12." The HA care plan documented by the Registered Nurse (RN) on 02/19/2025 assigned the HA the relevant tasks of showering with a shower bench, may provide sponge bath if patient refuses shower, observe and report skin changes in skin condition, and assist with toileting. The HA care plan did not provide the HA with instructions for the patient's colostomy. Clinical Record 7: The patient elected hospice care on 09/17/2024 with a diagnosis of colon cancer. The recertification comprehensive assessment completed by the SN dated 12/10/2024 for the certification period 12/16/2024 through 03/15/2025 documented that the patient had a colostomy in the left lower quad of the abdomen. The plan of care ordered HA services "4w1, 5w12." The HA care plan dated 09/17/2024 and updated on 10/14/2024, 01/29/2025, and 02/21/2025 assigned the HA the relevant tasks of sponge bath, incontinence care, and perineal care. The HA care plan did not provide the HA with instructions for the patient's colostomy. The Regional Director of Hospice confirmed the findings during a joint review of the HA care plans on 02/26/2025.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #7.12, "Competency Program," stated in part, "All clinical staff participates in the competency program...The competency program includes the following components: Job description for the position, describes the purpose and function of the position, identification of existing job/specific knowledge and skills, orientation competency checklist, discipline-specific skills competencies, and annual performance evaluation....Staff competence is initially assessed at orientation... After the initial orientation period staff competency is assessed annually. Completion of annual competency checklists is documented and filed in the clinician's personnel record... No member will be permitted to perform a skill or procedure independently until the related competency is successfully completed." In 2 of 10 (20%) personnel records reviewed, the agency did not ensure that the hospice assessed the skills and competencies of all individuals providing care per the agency's policy. Personnel Record 5: The employee was hired on 04/17/2017 as a Social Worker (SW) and began as a Bereavement Coordinator in February 2022. A personnel record review revealed annual performance evaluations for 2023 and 2024. There was no evidence of an annual competency checklist documented for the BC for 2023 and 2024 per the agency's policy. Personnel Record 6: The Volunteer Coordinator (VC) was hired on 05/17/2017. A personnel record review revealed annual performance evaluations for 2023 and 2024. There was no evidence of an annual competency checklist documented for the BC for 2023 and 2024 per the agency's policy. During a joint personnel record review and interview on 02/26/2025, the Regional Director of Hospice confirmed that the agency did not have a competency checklist for the Volunteer Coordinator and Bereavement Coordinator.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visit to a patient residing in a skilled nursing facility (SNF), the agency did not ensure that the designated IDG member provided the physician certification of terminal illness to the SNF. Home Visit 2/Clinical Record 2: The patient elected hospice care on 12/20/2024 and resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 01/25/2025, a review of the patient's SNF clinical record revealed that the SNF did not have a copy of the physician's certification of terminal illness (CTI). During a joint review of the SNF clinical record, the RN [Personnel Record 2] confirmed that the record did not include a CTI, stating they were unaware that a CTI was required to be provided to the facility. During an interview and a joint review of the record on 01/25/2025, the Regional Director of Hospice confirmed that the agency had not provided the physician certificate of terminal illness to the SNF, but they will start immediately.