Every finding on record at Adventa Hospice, LLC

Upon patient record review, 3 of 19 (Patients #6, 8, and 10) did not contain an individualized Plan of Care, to include all pertinent Advance Directive information: Patient #6: The admission consent reflects that the patient has a DPOA-Medical and a D.N.R. However, the DPOA-Medical is not included on the current 09/24/25 IDG Plan of Care. Patient #8: The admission consent reflects that the patient has a Living Will and a DPOA-Medical. However, the DPOA-Medical is not included on the current 09/24/25 IDG Plan of Care. Patient #10: The admission consent reflects that the patient has a Living Will, DPOA-Medical, and a D.N.R. However, neither the Living Will nor the DPOA-Medical is included on the current Plan of Care.

Upon patient record review, 1 of 19 (Patient #13) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the plan of care: Patient #13: Admitted on 08/29/25. The admitting RN provided Physician-ordered daily wound care to scalp, chest, right upper arm, and left knee. On the following day's visit, the RN documented, "Wound care not provided. Waiting for wound care orders."

Upon personnel record review, 1 of 13 (Personnel #8) did not contain evidence that the Hospice had conducted an Aide Skills Competency Evaluation as per CMS guidelines: Personnel #8: DOH 04/24/23. An Aide Skills Competency Evaluation was conducted between 04/26/2023 and 04/28/2023. However the following task was not evaluated/documented for: Normal Range of Motion. This line item had been left blank.

Upon observation, and interview with Administrator, there was not evidence of the Hospice's use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that at a minimum, equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. Surveyor was provided a 2024 calendar-year report reflecting a 0.93% rate.

Upon patient record review, 1 of 19 (Patient #6) did not contain evidence that each patient record contained copies of patient-reported Advance Directives: Patient #6: The admission consent reflects that the patient has a DPOA-Medical and a D.N.R. However, there is no copy of the DPOA-M filed within the clinical record.

Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that all entries were clear: Patient #8: The SOC Medical Director CTI reflected that the patient had a Stage 3 reddened area to right heel. The RN SOC assessment narrative section reflected a right heel wound. However, the same RN SOC assessment reflected a left heel wound in the graphic wound section, to include a detailed wound care protocol. A verbal order obtained 08/25/25 reflected a deep tissue injury to the right heel. The 08/25/25 SN visit note reflected a left heel wound, in the graphic wound section. A verbal order obtained 08/28/25 reflected a deep tissue injury to the left heel. The 08/28/25 SN visit note documented a blister on the right heel in the narrative, but reflected a left heel wound in the graphic wound section. The 09/24/25 IDG meeting note referenced a left heel blister that had dried up. A verbal order was obtained on 10/02/25 to discontinue wound care as the left heel had healed.

Upon Inpatient contract review, 2 of 5 (Pheasant Ridge Nursing & Rehab and Danville Regional Medical Center) did not contain evidence that these agreement(s) contained the required verbiage of: A copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from the Inpatient Facility.

Upon patient record review, 1 of 19 (Patient #1) did not contain evidence that the Hospice had provided the following information to the SNF: The Election of Hospice Benefit Statement: Patient #1: SOC 09/12/25. The SNF did not evidence that they had received an Election of Hospice Benefit Statement for this patient.

Upon personnel record review, 1 of 13 (Personnel #3) did not contain evidence of Criminal Background Checks having been obtained in accordance with Virginia State requirements, as follows: Section 32.1-162.9:1 of the Code of Virginia requires hospice providers, as defined in §32.1-162.1 of the Code of Virginia, to obtain a criminal record report on applicants for compensated employment from the Virginia Department of State Police. Section 32.1-162.9:1 also requires that all applicants for compensated employment in a hospice program provide a sworn statement regarding their criminal history. B. The criminal record report shall be obtained within 30 days of compensated employment. It is the hospice program's responsibility to ensure that its compensated employees have not been convicted of any of the barrier crimes listed in § 32.1-162.9:1 of the Code of Virginia. C. The hospice program shall not accept a criminal record report dated more than 90 days prior to the date of compensated employment. D. Only the original criminal record report shall be accepted. Personnel #3: DOH 12/30/24. The State Criminal Background Check in the file was dated 03/27/25; rather then within 30 days of compensated employment.

Based on a review of clinical records, select document review and staff interview it was determined the hospice agency failed to ensure the documentation of measurable outcomes for each problem documented on the plans of care for (13) of (13) records in the survey sample (Clinical record #'s 1-13). --- The findings: Thirteen (13) clinical records and two (2) bereavement records were reviewed via electronic medical record in read only mode on 01/23/2023 through 01/25/2023. The plan of care failed to contain measurable goals/outcomes for the patients listed below. The clinical record for patient #1 was reviewed for the time period of 11/02/2022 through 01/30/2023. The clinical record for patient #2 was reviewed for the time period of 07/03/2022 through 08/23/2022. The clinical record for patient #3 was reviewed for the time period of 07/21/2022 through 09/18/2022. The clinical record for patient #4 was reviewed for the time period of 09/04/2022 through 11/02/2022. The clinical record for patient #5 was reviewed for the time period of 10/14/2022 through 01/11/2023. The clinical record for patient #6 was reviewed for the time period of 01/05/2023 through 03/05/2023. Select Policy and Review: The policy, Hospice Plan of Care was reviewed on 01/24/2023. The policy partially reads as follows: Measurable outcomes anticipated from implementing the coordinating the plan of care. The clinical record for patient #7 was reviewed for the time period of 01/03/2023 through 04/02/2023. The clinical record for patient #8 was reviewed for the time period of 12/27/2022 through 02/24/2023. The clinical record for patient #9 was reviewed for the time period of 01/01/2023 through 3/01/2023. The clinical record for patient #10 was reviewed for the time period of 01/04/2023 through 04/03/2023. Staff interview: On 01/25/2023, the Medical Facilities Inspector asked the Area Vice President of Clinicals what led to the failure of no measurable goals on the plan of cares. The Area Vice President of Clinicals stated, " We need to make interventions more patient specific to help measure goals". The clinical record for patient #11 was reviewed for the time period of 12/31/2022 through 02/28/2023. The clinical record for patient #12 was reviewed for the time period of 12/02/2022 through 02/09/2023. The clinical record for patient #13 was reviewed for the time period of 10/25/2022 through 01/22/2023. The lack of documented measurable outcomes/goals on the above noted plans of care was acknowledged by the Director of Operations and the Area Vice President of Clinicals during the record reviews and again during the exit conference conducted in the agency on 01/25/2023.

Based on a review of the clinical records and staff interview it was determined the agency staff failed to ensure that all drugs were listed as a medication on the plan of care for two (2) of (13) patients in the survey sample (Clinical records# 5 and 6). --- The findings: Thirteen (13) clinical records and two (2) bereavement records were reviewed via electronic medical record in read only mode on 01/23/2023 through 01/25/2023. The clinical record for patient #5 was reviewed for the time period of 10/14/2022 through 01/11/2023. The care plan contained interventions for oxygen therapy; however, oxygen was not listed in the medication profile section of the care plan. In addition, the skilled nurse documented a medication named Metolazone was prescribed on 11/12/2022. The medication Metolazone was not listed in the medication profile. The clinical record for patient #6 was reviewed for the time period of 01/05/2023 through 03/05/2023. The skilled nurse documented a medication named Benadryl liquid to be used topically a few minutes before feeding to help with pain and inflammation on 01/11/2023. The medication Benadryl liquid was not listed in the medication profile. On 1/25/2023 at 11 AM the MFI asked the Director of Operations to review the medication profile to ensure the ordered treatments were included into the medication profile. The Director of Operations acknowledged the failure to include the above drugs and oxygen to meet the needs of the above noted patient. The lack to include all drugs to meet the needs of the above noted findings, was reviewed with the Director of Operations and the Area Vice President of Clinicals during the clinical records and again acknowledged the above noted findings during the exit conference on 1/25/2023.

Based on clinical record review, select document review and staff interview, it was determined the agency failed to ensure their Interdisciplinary Group (IDG) documented the patient's progress toward outcomes and goals specified in the plans of care for (13) of (13) clinical records in the survey sample with documented IDG meetings (Clinical Records: #1-13). --- The findings: Thirteen (13) clinical records and two (2) bereavement records were reviewed via electronic medical record in read only mode on 01/23/2023 through 01/25/2023 with the following findings: The clinical record for patient #1 with a start of care date of 11/02/2022 was reviewed for the timeframe of 11/02/2022 to 01/30/2023. Interdisciplinary Group (IDG) meetings were documented on 11/09/2022, 11/23/2022, 12/07/2022, 12/21/2022 and 01/04/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #2 with a start of care date of 09/11/2020 was reviewed for the timeframe of 07/03/2022 to 08/23/2022. Interdisciplinary Group (IDG) meetings were documented on 07/06/2022, 07/20/2022, 08/03/2022 and 08/17/2022. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #3 with a start of care date of 05/27/2021 was reviewed for the timeframe of 07/21/2022 to 09/18/2022. Interdisciplinary Group (IDG) meetings were documented on 07/27/2022, 08/10/2022, 08/24/2022 and 09/07/2022. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #4 with a start of care date of 09/04/2022 was reviewed for the timeframe of 09/04/2022 to 11/02/2022. Interdisciplinary Group (IDG) meetings were documented on 09/07/2022 and 09/21/2022. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #5 with a start of care date of 10/14/2022 was reviewed for the timeframe of 10/14/2022 to 01/11/2023. Interdisciplinary Group (IDG) meetings were documented on 10/19/2022, 11/02/2022 and 11/16/2022. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #6 with a start of care date of 07/25/2019 was reviewed for the timeframe of 01/05/2023 to 03/05/2023. Interdisciplinary Group (IDG) meetings was documented on 01/11/2023. The above noted IDG meeting failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #7 with a start of care date of 10/05/2022 was reviewed for the timeframe of 01/03/2023 to 04/02/2023. Interdisciplinary Group (IDG) meetings was documented on 01/11/2023. The above noted IDG meeting failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #8 with a start of care date of 06/30/2022 was reviewed for the timeframe of 12/27/2022 to 02/24/2023. Interdisciplinary Group (IDG) meetings were documented on 12/28/2022 and 01/11/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #9 with a start of care date of 03/07/2022 was reviewed for the timeframe of 01/01/2023 to 03/01/2023. Interdisciplinary Group (IDG) meetings were documented on 01/04/2023 and 01/18/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #10 with a start of care date of 10/06/2022 was reviewed for the timeframe of 01/04/2023 to 04/03/2023. Interdisciplinary Group (IDG) meeting was documented on 01/11/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. Select Policy and Review: The policy, Hospice Plan of Care was reviewed on 01/24/2023. The policy partially reads as follows: The revised POC (plan of care) must include information from the patient's updated comprehensive assessment and note the patient's progress toward the outcomes and goals specified in the plan. Staff interview: On 01/25/2023, the Medical Facilities Inspector asked the Director of Operations what led to the failure of IDG documenting the progress toward outcomes and goals. The Director of Operations stated, "We have been so focused on the declining issues and not so much the goals". Select Policy and Review: The policy, Hospice Plan of Care was reviewed on 01/24/2023. The policy partially reads as follows: The revised POC (plan of care) must include information from the patient's updated comprehensive assessment and note the patient's progress toward the outcomes and goals specified in the plan. The clinical record for patient #11 with a start of care date of 07/04/2022 was reviewed for the timeframe of 12/31/2022 to 02/28/2023. Interdisciplinary Group (IDG) meetings were documented on 01/04/2023 and 01/18/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #12 with a start of care date of 1/02/2019 was reviewed for the timeframe of 12/12/2022 to 02/09/2023. Interdisciplinary Group (IDG) meetings were documented on 12/14/2022, 12/28/2022 and 01/11/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The clinical record for patient #13 with a start of care date of 07/27/2022 was reviewed for the timeframe of 10/25/2022 to 01/22/2023. Interdisciplinary Group (IDG) meetings were documented on 10/26/2022, 11/09/2022, 11/23/2022, 12/07/2022, 12/21/2022, 01/04/2023 and 01/18/2023. The above noted IDG meetings failed to contain IDG documentation of the patient's progress toward outcomes and goals specified in the plan of care. Goals/outcomes were generalized. The lack of documentation by the agency's Interdisciplinary Group (IDG) regarding the patient's progress toward outcomes and goals specified in the plans of care for the above noted patients was acknowledged and confirmed by the Director of Operations and Area Vice President of Clinicals during the clinical record reviews and during the exit conference conducted in the agency on 01/25/2023.