Every finding on record at Bella Vita Healthcare LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed, the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/20/2024. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/23/2024. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/12/2025. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/01/2025. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of the comprehensive assessment. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed the initial bereavement assessments were not completed and stated the Spiritual Counselor/Bereavement Coordinator needed more education using the EMR [electronic medical record] system.

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed, the agency did not ensure the plan of care included patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/20/2024 with a diagnosis of carcinoma of the colon. The updated comprehensive nursing assessment dated 03/18/2025 included documentation that the physician ordered "Oxygen 2 Liters per minute via nasal cannula, as needed, for shortness of breath (SOB)." The updated plan of care dated 03/18/2025 did not include goal(s) and intervention(s) related to the patient’s respiratory status and shortness of breath. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/23/2024 with a diagnosis of cellulitis of finger. The initial nursing assessment dated 09/23/2024 included documentation that the patient had "Appetite fair to poor with 50-60% intake." The plan of care dated 09/23/2024 did not include goal(s) and intervention(s) related to the patient’s nutrition status. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/24/2024 with a diagnosis of acute kidney failure. The initial nursing assessment dated 05/24/2024 included documentation that the patient "Stays in bed most of day and has bowel and bladder incontinence." The plan of care dated 05/24/2024 did not include goal(s) and intervention(s) related to the patient’s bowel and bladder incontinence. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed the plans of care did not include goals and interventions related to problems identified in the initial and updated comprehensive assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed, the agency did not ensure the individualized plan of care included orders for drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 1: The patient elected the hospice benefit on 03/18/2025 with diagnosis of acute kidney failure. The initial nursing assessment dated 03/18/2025 included documentation that "The patient has a (sixteen) 16 French Foley catheter with a ten (10) milliliter balloon and the patient has bladder incontinence." The plan of care dated 03/18/2025 did not include an order for the Foley catheter that specified the size of the catheter and the balloon size. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/20/2024 with diagnosis of carcinoma of the colon. The updated comprehensive nursing assessment dated 03/18/2025 included documentation that the physician ordered "Oxygen 2 Liters per minute via nasal cannula, as needed, for shortness of breath (SOB) and Oxygen saturation of 86%." The plan of care dated 03/18/2025 did not include an order for oxygen. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee agreed the orders were not on the plans of care.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 7 of 7 (100%) clinical records reviewed with patient death, the agency did not ensure a bereavement plan of care was developed for the bereaved. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/23/2024 and the clinical record included documentation that the patient’s death was dated 10/04/2024. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 5: The patient elected the hospice benefit on 09/02/2024 and the clinical record included documentation that the patient’s death was dated 09/30/2024. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/10/2024 and the clinical record included documentation that the patient’s death was dated 09/20/2024. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/24/2024 and the clinical record included documentation that the patient’s death was dated 08/10/2024. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/20/2024 and the clinical record included documentation that the patient’s death was dated 07/14/2024. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/12/2025 and the clinical record included documentation that the patient’s death was dated 01/20/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/30/2024 and the clinical record included documentation that the patient’s death was dated 01/02/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed the bereavement plans of care were not completed and stated the Spiritual Counselor/Bereavement Coordinator needed more education using the EMR [electronic medical record] system.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide reported changes in the patient's medical and rehabilitation needs to the Registered Nurse as the changes related to the aide care plan. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/24/2024. The aide care plan dated 06/03/2024 included an order for aide frequency of visits two times per week and assigned the aide the task of "Mechanical lift." The aide did not document the task of Mechanical lift was completed on the aide visit note dated 06/28/2025 and there was no documentation to explain why the task was not performed. The record did not include documentation that the aide reported any changes in the patient's medical and rehabilitative needs to the Registered Nurse as related to the "Mechanical lift" ordered. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed there was no documentation in the record that the aide reported the task not completed to the nurse.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse documented hospice aide supervisory visits no less frequently than every 14 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/20/2024. The aide plan of care for the episode of care dated 03/19/2025 to 05/17/2025 included an order for aide services at a frequency of four times per week. The clinical record included documentation that the aide had provided visits four times per week from 03/19/2025 through the date of record review on 05/01/2025. There was no documented evidence in the clinical record that aide supervisory visits had been completed, from 03/19/2025 through the date of record review on 05/01/2025, a total of 43 days. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/24/2024. The updated aide plan of care dated 06/03/2024 for the episode of care dated 05/24/2024 to 08/10/2024 included an order for aide services at a frequency of two times per week. The clinical record included documentation that the aide had provided visits two times per week from 06/03/2024 through 08/10/2024. There was no documented evidence in the clinical record that aide supervisory visits had been completed from 06/03/2024 through 08/10/2024, a total of 68 days. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/20/2024. The updated aide plan of care dated 06/03/2024 for the episode of care dated 04/20/2024 to 07/14/2024 included an order for aide services at a frequency of two times per week. The clinical record included documentation that the aide had provided visits two times per week from 06/03/2024 through 07/14/2024. There was no documented evidence in the clinical record that aide supervisory visits had been completed from 06/03/2024 through 07/14/2024, a total of 41 days. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee agreed that aide supervisory visits were not documented at least every 14 days.

It is required that each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness, as required. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed, the agency did not ensure the initial certification of terminal illness (CTI) was signed and dated by the physician. CLINICAL RECORD 3: The Nurse Practitioner, who was employed by the agency, signed and dated the initial CTI on 09/20/2024. However, there was no documented evidence that the CTI was signed by the physician. CLINICAL RECORD 4: The Nurse Practitioner, who was employed by the agency, signed and dated the initial CTI on 09/23/2024. However, there was no documented evidence that the CTI was signed by the physician. CLINICAL RECORD 5: The Nurse Practitioner, who was employed by the agency, signed and dated the initial CTI on 09/02/2024. However, there was no documented evidence that the CTI was signed by the physician. CLINICAL RECORD 6: The Nurse Practitioner, who was employed by the agency, signed and dated the initial CTI on 09/10/2024. However, there was no documented evidence that the CTI was signed by the physician The Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee agreed in an interview on 05/02/2025 that the agency had not ensured the initial CTIs were signed and dated by a physician. The Owner stated, "The agency hasn't billed Medicare for hospice services provided to the patients that the initial CTI wasn't signed by a physician" and "The Nurse Practitioner is no longer an employee."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed where the patient revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 09/19/2024 and revoked hospice care on 12/20/2024. There was no documented evidence in the clinical record that the agency forwarded a copy of the discharge summary to the patient's attending physician. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed that the discharge summary was not forwarded to the physician.

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for a patient that was receiving hospice services in a Skilled Nursing Facility (SNF), the agency did not ensure that the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon based on the needs of the patient. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/24/2024 with diagnosis of acute kidney failure. The patient resided in a Skilled Nursing Facility. The hospice plan of care did not include documentation of which provider was responsible for performing the care and services that were included in the patient's plan of care. During an interview and review of findings on 05/02/2025, the Owner/Volunteer Coordinator/Licensed Vocational Nurse, the Director of Patient Care Services (DPCS), and the DPCS Designee confirmed the patient’s plan of care did not designate which provider was responsible for the cares listed on the plan of care.

Observed in Tracer Activities. The organization did not initiate any alternate plan to manage interruptions to its information processes. Clinical documentation was not recorded in the absence of their Electronic Health Record.

Observed in Record Review. In 1 of 1 records where the patient revoked services, a revocation document was not signed by the patient or designee at the time of discharge in record RRNHV#5. Observed in Record Review. In 2 of 5 patient records reviewed, the patient or designee did not sign the hospice Election of Benefits document at the start of care in records RRNHV#1 and RRNHV#2.

Observed in Tracer Activities. The organization failed to maintain confidential records. The LPN who joined this hospice four months ago kept paper notes containing PHI for several patients on a clip board that she took with her when making patient visits. And, with the recent absence of an Electronic Health Record (EHR) she wrote notes on her personal iPad with the intent to enter them into the EHR when it became available.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to protect patients’ rights to be free from neglect. In records RRNHV#1, RRNHV#4, and RRNHV#5 medications had not been provided for two to five months. In RRNHV#3 no orders were written for medications. And in RRNHV#2 and RRNHV#4 DME was not provided. Additionally, in RRNHV#1 there was one RN visit documented 12 days after admission. In the other four records there were no RN visits documented. All patients were receiving services for three to five months.

Observed in Record Review. In 5 of 5 patient records reviewed, initial comprehensive assessments and re-assessments were not documented by nursing, medical social wervices, and spiritual counseling services for patients receiving services for three to five months.

Observed in Record Review. In 5 of 5 patient records reviewed, initial comprehensive assessments by a registered nurse were not documented within 48 hours of admission, nor were any comprehensive re-assessments documented for patients who were receiving services for three to five months.

Observed in Record Review. This finding contributed to the immediate threat to health and safety decision and cannot be clarified. In 5 of 5 records reviewed there were no documented RN patient assessments or reassessments since October 2024. The immediate mitigation plan implemented included: APN to see current patients on 2/11/25 and to cover all required nursing care and oversight until the Director of Nursing (DON) returns from vacation on 2/20/25.

Observed in Record Review. In 5 of 5 patient records reviewed, plans of care were not created and/or revised. There were no plans included in the record for RRNHV#1, RRNHV#3, RRNHV#4, and RRNHV#5. In RRNHV#2 a plan of care was created but not revised for the last two months.

Observed in Tracer Activities. The interdisciplinary group did not include a social worker and spiritual counselor.

Observed in Record Review. In 4 of 5 patient records reviewed, individualized plans of care were not created. As a result, there were no measurable outcomes established.

Observed in Record Review. In 5 of 5 patient records reviewed, interdisciplinary team meetings with a physician, social work and spiritual counselor present did not occur every 15 days or less. In two records no meetings were documented, and in three records only one meeting was documented. Every patient had been on hospice services from three to five months. Also, during a discussion with the Medical Director he reported that he attended meetings only monthly and the Nurse Practitioner attended in his absence.

Observed in Tracer Activities. In the absence of a registered nurse, there was no one to supervise licensed professional nursing services as required by the Condition of Participation.

Observed in Tracer Activities. The organization did not have an officially designated registered nurse to coordinate care, participate in the interdisciplinary assessment and evaluation process, and contribute to the counseling and education of the patient and family.

Observed in Tracer Activities. Medical Social Services were not provided. The administrator stated that there had not been a social worker available for a year.

Observed in Tracer Activities. Spiritual counseling services were not provided. The administrator stated that there had not been a spiritual counselor available for a year.

Observed in Record Review. In 1 of 1 patient records reviewed where the patient expired, there was no bereavement plan of care documented specifying the types of services offered and the frequency of delivery.

Observed in Tracer Activities. During review of contracts, it was determined that there were no occupational and speech-language pathology services available.

Observed in Record Review. In 5 of 5 patient records reviewed, there was no documentation that a registered nurse supervised the hospice aide during an on-site visit to the patient's home every 14 days or less. For example, in RRNHV#1 there was one supervisory visit documented 19 days after admission. In the other four records there were no supervisory visits documented. All patients were receiving services for three to five months.

Observed in Tracer Activities. This finding contributed to the immediate threat to health and safety decision and cannot be clarified. Leaders did not manage implementation of patient care policies and procedures governing the provision of care. Evidence of non-compliance with standards was identified in the following chapters: Accreditation Participation Requirements, Human Resources, Information Management, Provision of Care, Record of Care, and Rights and Responsibilities. The immediate mitigation plan implemented included: APN to see current patients on 2/11/25 and to cover all required nursing care and oversight until the Director of Nursing (DON) returns from vacation on 2/20/25. Bills had been paid for the Electronic Health Record and access had been restored as of end of the survey. Observed in Tracer Activities. The governing body did not assume legal authority and responsibility for the management of the provision of services. When asked about the role of the governing body the administrator was not able to answer the question or provide documentation of its' activities. Observed in Tracer Activities. The governing body did not ensure that the Conditions of Participation were met as determined through observations, documentation, and staff interviews. Condition level deficiencies include §418.100, §418.102, §418.104, §418.106, §418.113, §418.52, §418.56, §418.62, §418.64, and §418.72. Observed in Tracer Activities. The administrator was not able to provide written documentation of her appointment to the role.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. The organization was not providing hospice services as required by Medicare, including nursing services, medical social worker, counseling, therapy services, medications, durable medical equipment or supplies.

Observed in Tracer Activities. The organization did not make services and medications available 24 hours a day. Calls were made to the office phone number at 9:00 pm and again at 6:00 am. Each time the phone rang 4 times and then disconnected.

Observed in Tracer Activities. The organization did not have a physician available to act as alternate medical director. A nurse practitioner was in that role.

Observed in Record Review. In 2 of 5 patient records reviewed, certificates of terminal illness in record RRNHV#2 for a patient who expired seven weeks after admission, and record RRNHV#3 where a patient had received services for 11 weeks prior to this survey date had not been completed as part of the hospice certification process.

Observed in Regulatory Review. In 3 of 5 patient records reviewed, certificates of terminal illness in records RRNHV#1, RRNHV#4, and RRNHV#5 had not been completed as part of the hospice recertification process.

Observed in Tracer Activities. This finding contributed to the immediate threat to health and safety decision and cannot be clarified. In 5 of 5 patient records reviewed, the organization failed to develop or implement a process for when medical records were not available, as evidenced by the organization losing access to their medical records due to non-payment without an implemented process to place orders or document care, treatment, and services provided. A clinical record was not maintained for each patient. When the surveyor requested access to the Electronic Health Record it was learned that this could not be accomplished. It was also discovered that staff had no access for the past one to two weeks. As well, leaders did not have an alternate process for recording care delivery information. The immediate mitigation plan implemented included: Bills have been paid for Electronic Health Record and access has been restored as of end of survey.

Observed in Record Review. In 5 of 5 patient records reviewed, patient records did not contain the following information: changes in the patient's condition; summaries of care, treatment, or services; the patient's response to care, treatment, or services; assessments relevant to care, treatment, or services; and plans of care.

Observed in Tracer Activities. In 5 of 5 patient records reviewed, Leaders did not provide supplies, durable medical equipment, and medications to patients. In discussions with staff, patient record audits and review of delivery receipts from the pharmacy and company providing equipment it was evident that items needed for the palliation and management of patients' illnesses were not furnished. For example, medications were not delivered for at least 2 or more months; equipment was not ordered nor were wound supplies, chux and adult briefs provided.

Observed in Record Review. In 5 of 5 patient records reviewed, the Surveyor noted the Medical Social Worker (MSW) had not completed an initial assessment within 5 days after the election of hospice benefit. HV #1, HV #2, HV #3, RR #4 and RR #5 all had orders for MSW: Initial evaluation within 5 days of SOC to identify psychosocial concerns/ needs of the patient, family/cg; however, there had been no documented MSW visit in the EMR. RR #4 and RR #5 had a comprehensive MSW note generated but it had contained no documentation. This was validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the Surveyor noted that the patient care goals in all records were broad and not measurable. Examples include: for genitourinary status: Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. For pain: Pain will remain in comfortable level during care with non-pharmacologic and pharmacologic measures. Respiratory- Pt will have optimum level of oxygen. For nausea-The patient will be able to demonstrate strategies that prevent nausea, and for falls: patient/pcg will minimize the complications and able to identify the complications and cause of impaired mobility. This was validated with the Director of Nursing and Administrator.

Observed in Record Review. In 3 of 5 patient records reviewed, the Surveyor noted not all patient needs had been addressed on the plan of care (POC) with interventions and goals. HV #1, the patient had a trach and a J-tube; however, neither had been addressed on the POC. The patient had also had a recent upper respiratory infection but this had not been added to the POC. RR #4, the patient had a new onset urinary tract infection. The POC had not contained interventions and goals to address this. In RR #5, the patient had an indwelling urinary catheter, but this had not been included on the POC. This was validated with the Administrator. Observed in Record Review. In 3 of 5 patient records reviewed, the Surveyor noted incomplete as needed medication orders. For example, HV #1 had Ibu-200 200mg 1 Tab Oral Every 6 hrs. PRN Pain, Oxycodone Hydrochloride 100mg/5mL Concentrated Solution Note: Take 0.25 ml every 6 hrs. prn ,Severe pain and Acetaminophen 500mg Caplet 1 Tab Oral Every 6 hours PRN Mild pain. The patient also had Phenergan 25mg Tablet every 6 hours as needed Nausea/vomiting and Compazine 10mg Tablet Every 6 hrs. as needed nausea, vomiting. HV #2 had Morphine Sulfate 100mg/5mL Solution 0.25 ml Sol Sublingual Every 2 hrs PRNPain and Oxycodone Hydrochloride 10mg Tablet 1 Tab Oral Take 1 tab daily every 4 hours as needed for Pain – Moderate. RR #4 had Oxycodone Hydrochloride 5mg,1 Tab Oral PRN every 6 hours Pain - Moderate- Severe, and Oxycodone Hydrochloride 5mg, 1 Tab Oral every 6 hrs, PRN Severe pain. This was validated with the Director of Nursing and the Administrator.

Observed in HR File Review. In 1 of 6 HR files reviewed, the Surveyor noted a background check had been missing from the HR file. HR #3, there had been no documented background check. This was validated with the Owner and Administrator.