Every finding on record at Care Alternatives of Virginia, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current Prescription and over the counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 19 (32%) records reviewed the agency did not ensure that the medication profile contained all of the patient's current prescription and over the counter drugs. Document 2: Policy No. H:2-055.1 Medication profile read in part, “1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of initial and comprehensive assessments, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” Clinical Record 5: The election of hospice was 12/21/2023. The initial comprehensive assessment dated 12/21/2023 and the 01/03/2024 and 01/17/2024 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 2LPM via nasal cannula. At the time of the review on 01/23/2024, oxygen was not included on the profile. Record 6: The election of the hospice benefit was 12/19/2023. The 12/19/2023 initial comprehensive, as well as the 12/20/2023, 01/03/2024 and 01/17/2024 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 4LPM via nasal cannula. At the time of the review on 01/23/2024, oxygen was not included on the medication profile. Clinical Record 8: The hospice election of benefit was 12/22/2023. The12/22/2023 initial comprehensive assessment, as well as the 01/03/2024 and 01/17/2024 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 2LPM via nasal cannula. At the time of the review on 01/23/2024, oxygen was not included on the medication profile. Clinical Record 12: The hospice election of benefit was 12/19/2023. The 12/19/2023 initial comprehensive assessment, as well as the 12/20/2023, 01/03/2024, and the 01/17/2024 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 2-5LPM via nasal cannula. At the time of the review on 01/24/2024, oxygen was not included on the medication profile. Clinical Record 16: The election of the hospice benefit was 11/16/2023. The 11/16/2023 initial comprehensive assessment, as well as the 11/22/2023 and the 12/06/2023 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 4LPM via nasal cannula. At the time of the review on 01/24/2024, oxygen was not included on the medication profile. Clinical Record 17: The election of the hospice benefit was 12/07/2023. The 12/07/2023 initial comprehensive assessment, as well as the 12/20/2023 and the 01/03/2024 updated hospice plans of care and interdisciplinary team meeting medication profile review notes included the patient use of Oxygen at 2-5LPM via nasal cannula. At the time of the review on 01/24/2024, oxygen was not included on the medication profile. During interview on 01/25/2023, the DPCS reviewed the associated records and stated that Oxygen had inadvertently been omitted form the medication profiles and had since been corrected.

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, document review and interview. In 1 of 19 (5%) records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Document 6: Policy No. H:2-053.1 Bereavement Assessment read in part, “1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator.” Clinical Record 3: The hospice election of benefit was dated 08/07/2023. The registered nurse documented completion of the comprehensive start of care assessment on 08/07/2023. At the time of the review on 01/23/2024, the initial bereavement assessment was documented as completed on 09/07/2023 by the social worker. During interview 01/25/2024, the DPCS reviewed the associated record and stated that the initial bereavement assessment was completed late, and the associated clinicians had since been provided remedial education to prevent future recurrence.

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, document review and interview. In 16 of 19 (84%) records reviewed the agency failed to include interventions and goals related to self-care deficit problems identified on the initial and updated comprehensive assessments requiring the provision of aide services. Document 5: Policy No. PC. P45 Plan of Care Content read in part, “The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. 2. The plan of care includes but is not limited to: a. interventions to manage pain and symptoms c. measurable outcomes anticipated from implementing and coordinating the plan of care.” Clinical Record 1: The hospice election of benefit was dated 07/14/2023. A review of the hospice plan of care dated 11/11/2023 included an aide frequency of 1week1, 2week 8. The 11/20/2023, 11/22/2023, 12/06/2023, 12/20/2023, 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 2: The hospice election of benefit was dated 01/19/2023. A review of the 11/15/2023 hospice plan of care included an aide frequency of 5week8, 3week1. The 11/15/2023, 11/22/2023, 12/06/2023, 12/20/2023, 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 3: The hospice election of benefit was dated 08/07/2023. A review of the hospice plan of care dated 11/05/2023 included an aide frequency of 5week13. The 11/05/2023, 11/08/2023, 11/29/2023, 12/06/2023, 12/20/2023, 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 5: The hospice election of benefit was dated 12/21/2023. The 12/21/2023 hospice plan of care included an aide frequency of 1week1, 2week12. The 12/21/2023, 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 6: The hospice election of benefit was dated 12/19/2023. The 12/19/2023 hospice plan of care included an aide frequency of 1week1. The 12/19/2023 initial and the 12/20/2023 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 8: The hospice election of benefit was dated 12/22/2023. The 12/22/2023 hospice plan of care included an aide frequency of 2m1, 9m1. The 12/22/2023 initial and the 12/28/2023 and 01/10/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 9: The hospice election of benefit was dated 08/23/2023. A review of the hospice plan of care dated 11/26/2023 included an aide frequency of 2week5, 3week8. The 12/06/2023, 12/20/2023, 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 10: The hospice election of benefit was dated 10/03/2023. A review of the hospice plan of care dated 12/2902023 included an aide frequency of 2week5, 2week8. The 12/29/2023 initial and the 01/03/2024 and the 01/17/2024 updated comprehensive assessments and associated updated hospice plans of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/23/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 11: The hospice election of benefit was dated 12/14/2023. The 12/14/2023 hospice plan of care included an aide frequency of 1week9. The 12/14/2023 initial and the 12/20/2023, 12/28/2023 and 01/11/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 12: The hospice election of benefit was dated 12/19/2023. The 12/19/2023 hospice plan of care included an aide frequency of 1week1, 2week8. The 12/19/2023 initial and the 12/20/2023, 01/03/2024 and 01/17/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 13: The hospice election of benefit was dated 12/06/2023. The 12/06/2023 hospice plan of care included an aide frequency of 1week1, 2week12. The 12/06/2023 initial and the 12/20/2023, 01/03/2024 and 01/17/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 14: The hospice election of benefit was dated 12/05/2023. The 12/05/2023 hospice plan of care included an aide frequency of 1week1, 2week8. The 12/05/203 initial and the 12/14/2023, 12/28/2023, and 01/11/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 16: The hospice election of benefit was dated 11/16/2023. The 11/16/2023 hospice plan of care included an aide frequency of 2week12. The 11/16/2023, 11/22/2023 and 12/06/2023 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 17: The hospice election of benefit was dated 12/07/2023. The 12/07/2023 hospice plan of care included an aide frequency of 1week1, 2week12. The 12/07/2023 initial and the 12/20/2023 and 01/03/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 18: The hospice election of benefit was dated 11/01/2023. The 11/01/2023 hospice plan of care included an aide frequency of 2week1, 5week12. The 11/01/2023 initial and the 11/08/2023, and 11/22/2023 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. Clinical Record 19: The hospice election of benefit was dated 01/16/2024. The 01/16/2024 hospice plan of care included an aide frequency of 2week9. The 01/16/2024 initial and the 01/17/2024 updated comprehensive assessments and associated updated hospice plan of care included the continued aide frequency with the noted problem of self-care deficit and identified need for assistance with personal care. At the time of the review on 01/24/2024 however, the self-care deficit problem related interventions and goals were not included on the plans of care. During interview on 01/25/2024, the DPCS reviewed the associated records and stated that this was a learning opportunity as while aide task assignments and subsequent interventions and goals had been discussed with the creation of the aide assignment/tasks, they had inadvertently been omitted form the hospice plans of care and had since been corrected.

It is required that all hospice aide provides services ordered by the Interdisciplinary Group and Included in the plan of care. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section {HCPC.15. I/L625}; Failed to ensure 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 {HRSM. 25. I/L629}; and failed to ensure 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 {HCPC.21. I/L545}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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 registered nurse (RN) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 16 (19%) records reviewed with the provision of aide services; the agency did not ensure that the written instructions prepared by the Registered Nurse were patient specific. Document 3: Policy No. PC.H20 Hospice Adie Assignments and Duties read in part, “1. The hospice RN responsible for supervising the hospice aide prepares written patient care instructions that are patient specific and not generic.” Clinical Record 8: The 12/22/2023 hospice plan of care included wound care orders for the left foot, sacrum, buttocks, and the right heel. The 12/22/2023 aide care plan created by the registered nurse did not contain instructions/precautions related to the wounds with the provision of ADL/IADL assistance at the time of the review on 01/23/2024. Clinical Record 13: The 12/06/2023 hospice plan of care included wound care orders for the left lower extremity and the right heel. The 12/06/2023 aide care plan created by the registered nurse did not contain instructions/precautions related to the wounds with the provision of ADL/IADL assistance at the time of the review on 01/24/2024. Clinical Record 16: The 11/16/2023 hospice plan of care included wound care orders for a stage II sacral wound. The 11/19/2023 aide care plan created by the registered nurse did not contain instructions/precautions related to the wound with the provision of ADL/IADL assistance at the time of the review on 01/24/2024. During interview 01/25/2024, the DPCS reviewed the associated records and stated that the instructions related to the wound have since been added by the supervising registered nurse and the education had since been provided to the assigned aides.

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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 16 (6%) records reviewed with the provision of aide services; the agency did not ensure that a registered nurse made an on-site aide supervisory visit to the patient’s home no less frequently than every 14 days. Document 4: Policy No. PC.H30 Hospice Aide Supervision read in part, “1. A registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's need.” Clinical Record 13: The 12/06/2023 hospice plan of care included an aide visit frequency of 1week1, 2week12. Aide services were provided as per ordered frequency 12/07/2023 through 01/22/2024. At the time of the review on 01/23/2024, the first aide supervisory visit was documented on 12/27/2023. The supervisory visit dates exceeded every 14-day minimum requirement. During interview 01/25/2024, the DPCS reviewed the associated record and stated that the supervisory visits had inadvertently been missed.