Every finding on record at Caresouth HHA Holdings of Winchester, LLC

Based on policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the hospice's own policies and procedures by failing to ensure clinical notes were documented in a timely matter for 2 of 10 (Patient #8 and #14) patients reviewed. --- The findings included: Review of the agency's "Discipline-specific Documentation," policy dated 3/11/2025, revealed, "...Direct-care staff members should document services and treatments delivered while in the patient's home or place of residence, whenever possible. For visits performed during business hours, visits should be completed and synched by 10:00 PM on the same day of service delivery..." Review of the medical record revealed Patient #8 was admitted to the agency on 5/3/2025 with diagnoses including Terminal Atherosclerotic Heart Disease. Review of the skilled nursing note dated 5/23/2025, revealed the visit began at 3:39 PM. The visit was documented as completed on 5/25/2025 at 10:20 AM.Review of the social worker note dated 6/6/2025, revealed the visit began at 10:33 AM. The visit was documented as completed on 6/8/2025 at 8:25 AM.Review of the social worker note dated 6/13/2025, revealed the visit began at 10:01 AM. The visit was documented as completed on 6/15/2025 at 10:59 PM.Review of the skilled nursing note dated 6/20/2025, revealed the visit began at 10:13 AM. The visit was documented as completed on 6/23/2025 at 9:39 AM.Review of the skilled nursing note dated 6/25/2025, revealed the visit began at 10:17 AM. The visit was documented as completed on 6/27/2025 at 10:30 AM. Review of the medical record revealed Patient #9 was admitted to the agency on 7/16/2024 with diagnoses including Terminal Atherosclerotic Heart Disease.Review of the skilled nursing note dated 5/16/2025, revealed the visit began at 8:44 AM. The visit was documented as completed on 5/19/2025 at 6:05 AM. During an interview on 7/15/2025 at 3:40 PM, the Branch Director stated, "...It is not the norm for the staff to chart their findings late, but there are sometimes it can't be avoided. I do expect the staff to chart while in the patient's residence or at least within 24 hours..."

Based on agency policy review, medical record review, and interview the agency failed to update the medication profile for 1 patient (#2) of 3 patients reviewed with home visits. The findings include: Review of the agency's policy titled, "Medications," revised 10/4/2021, showed "...Staff assesses all medications a patient may be taking...Staff will assess every visit and document assessment on the visit note..." Medical record review revealed Patient #2 was admitted to the agency on 11/11/2021 with diagnoses including Acute Kidney Failure With Tubular Necrosis and Hemiplegia Following Cerebral Infarction. Further reviewed showed the patient resided in an Assisted Living Facility (ALF). Medical record review of Patient #2's current ALF Order Summary Report dated 12/7/2021, showed the patient had orders for the following medications: Hyoscyamine Sulfate (a medication for secretions) tablet 0.125 mg (milligram) every 6 hours as needed, and Morphine Sulfate (a pain medication) solution 20 mg/ml (milliliter) give 0.5 ml by mouth every 3 hours as needed. Further review showed no order for Haloperidol lactate (an antipsychotic medication). Medical record review of Patient #2's agency medication profile dated 12/8/2021, showed the patient had orders for the following medications: Hyoscyamine Sulfate tablet 0.125 mg every 4 hours as needed, Morphine Sulfate solution 20mg/ml give 0.25 ml by mouth every 2 hours as needed, and Haloperidol lactate 2 mg/ml give 0.5 ml every 4 hours as needed with a start date of 11/11/2021. During an interview on 12/8/2021 at 10:00 AM, the Branch Manager confirmed the agency's medication list showed Hyoscyamine Sulfate was to be administered every 4 hours as needed and the ALF medication list showed every 6 hours, the agency's medication list showed the Morphine Sulfate was to be administered every 2 hours as needed at a dose of 0.25 ml and the ALF's medication record showed the Morphine was to be administered every 3 hours as needed at a dose of 0.5 ml, and the agency's medication list had an order for Haloperidol Lactate to be administered every 4 hours as needed and the ALF did not have that medication listed. The Branch Manager Confirmed the agency had not reconciled the medication list for Resident #2.

Based on medical record review and interview, the agency failed to furnish services indicated by the individualized written Plan of Care (POC) established by the hospice interdisciplinary team for 2 patients (#2 and #4) of 11 patients reviewed. The findings include: Medical record review revealed Patient #2 was admitted to the agency on 11/11/2021 with diagnoses to include Acute Kidney Failure With Tubular Necrosis, and Hemiplegia Following Cerebral Infarction. Medical record review of Patient #2's POC for the certification period 11/11/2021-1/9/2022 showed frequency for Skilled Nurse (SN) visits were 2 times a week for 1 week, then 3 times a week for 8 weeks. Medical record review of the SN notes for Resident #2 showed the week of 11/21/2021-11/27/2021 the SN completed visits on 11/22/2021 and 11/27/2021. The POC showed 3 visits were to be completed. Medical record review revealed Patient #4 was admitted to the agency on 4/20/2020 with diagnoses to include Chronic Respiratory Failure With Hypoxia, COPD, and Heart Failure. Medical record review of Patient #4's POC for the certification period 10/17/2021-12/15/2021 showed frequency for Hospice Aide (HA) visits with an effective date of 10/17/2021 were 2 times a week for 8 weeks, then 1 time a week for 1 week. Medical record review of the HA visits showed the week of 11/21/2021-11/27/2021 the HA completed a visit on 11/24/2021. Further review showed there had been a scheduled visit on 11/26/2021, the visit had not been completed, and the POC showed 2 visits were to be completed. During an interview on 12/8/2021 at 9:59 AM, HA #1 stated she had not completed a visit for Resident #4 on 11/26/2021. During an interview on 12/8/2021 at 10:10 AM, the Branch Manager confirmed Resident #2 had a missed SN visit the week of 11/22/2021-11/27/2021. Further interview confirmed Resident #4 had a scheduled HA visit on 11/26/2021 and the visit had not been completed.