Every finding on record at Western Health Resources - Adventist Health System West

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas: they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by interview and personnel record review. 1 of 1 (100%) personnel record of a hospice aide (HA) reviewed revealed the agency did not ensure evaluation of the aide's competency by observation of the aide's performance prior to independent assignment of patient care, and subsequent to assignment of patient care. PERSONNEL RECORD 10: The HA was hired on 08/12/2024. There was no documented evidence that the agency evaluated the aide's competency by observation of the aide's performance before the aide began providing HA services to patients. The HA began making visits on 08/15/2024. There was no documented evidence of a competency evaluation prior to 09/18/2025. There was a documented competency evaluation dated 09/18/2025 in the record but the evaluation did not include evidence that the aide was observed completing the required tasks of oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion. During a joint personnel record review and interview on 12/19/2025, the Office Manager agreed there was no documented evidence of a competency evaluation upon hire. The Office Manager stated, "I discovered there was not a competency completed when I was new to the role and auditing files. It was then completed a year later." During a joint personnel record review and interview on 12/19/2025, the Clinical Manager agreed there was no documented evidence that the agency evaluated the aide's competency by observation of the aide's performance. Additionally, the Clinical Manager agreed that the competency evaluation dated 09/18/2025 was completed a year after the aide had been providing aide services and it did not include evidence that the aide was observed completing, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion.

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 which revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Hospice Volunteer Requirement Report was reviewed for the combined totals of the parent and ADS (alternate delivery site). The report for January 2024-December 2024 revealed the volunteer hours were 3.67%. The report for January 2025-December 2025 revealed the volunteer hours were 3.45%. There was no documented evidence that the volunteers provided at least 5% of the total patient care hours. During an interview on 12/18/2025, the Volunteer Coordinator (ADS) agreed that the 5% requirement was not met in 2024 or 2025. Additionally, the Volunteer Coordinator stated, "This is a small town so its challenging. We are working to improve our recruitment efforts." During an interview on 12/18/2025, the Clinical Manager (ADS) agreed that the 5% requirement was not met in 2024 or 2025. Additionally, the Clinical Manager stated, "We realized the previous Volunteer Coordinator was not connected to the community so we hired a new one." During an interview on 12/19/2025, the combined reports were reviewed with the Clinical Manager (Parent). The Clinical Manager agreed that the 5% requirement was not met in 2024 or 2025. Additionally, the Clinical Manager stated that a new Volunteer Coordinator (Parent) was in orientation and had just started this month (December 2025). The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.