Every finding on record at Curo Health Services, LLC

Upon patient record review 5 of 23 (Patient #7,#10,#13,#15,#17) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#7: The record indicates patient admitted on 08/06/24. There is evidence that the initial spiritual assessment wasn't completed until 06/11/25. Patient#10: The record indicates patient admitted on 01/17/25. There is evidence that the initial spiritual assessment wasn't completed until 01/23/25. Patient#13: The record indicates patient admitted on 01/9/25. There is evidence that the initial spiritual assessment wasn't completed until 01/17/25. Patient#15: The record indicates patient admitted on 05/1/24. There is evidence that the initial spiritual assessment wasn't completed until 07/03/25. Patient#17: The record indicates patient admitted on 04/30/25. There is evidence that the initial spiritual assessment wasn't completed until 05/08/25.

Upon patient record review, 1 of 23 (Patient #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#8: During home visit, it was confirmed with patient that he is currently taking amlodipine 5mg 1 daily. However, there is no evidence of this medication on the medication profile. In order to correct on site, the agency updated the medication profile with this medication.

Upon patient record review, 1 of 23 (Patient #13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#13: The record indicates patient admitted to services on 01/09/25. There is evidence in record that initial bereavement assessment was not completed until 06/02/25.

Upon patient record review, 4 of 23 (Patient #2,#6,#8,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#2: The record indicates the patient has a foley catheter in place. There is no evidence of interventions related to changing or replacing the foley catheter. This was corrected on site but the agency updated the care plan with interventions related to changing/replacing the foley catheter. Patient#6: The record indicates that the care plan does not include interventions for current treatment orders for the stage 2 calf wound or the stage 3 coccyx wound. In order to correct on site, the agency updated care plan with interventions for treatment of both wounds. Patient#8: The record indicates patient has lost 20 pounds, per 6/3 RN visit patient has esophagitis and skips dinner, per 6/25 RN visit has started using Ensure, and has poor appetite. There is no evidence of problems goals and interventions related to patient nutritional needs on care plan. In order to correct on site, the care plan was updated by agency. Patient#10: The record indicates aspiration precautions are indicated on the aide plan of care. There is no evidence of aspiration precautions being on the care plan. In order to correct on site, the agency updated the care plan to include aspiration precautions.

Upon patient record review, 2 of 23 (Patient #2,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#2: There is no evidence of an order for foley catheter to be changed or replaced. In order to correct on site, an order was entered into chart. Patient#4: The record indicates the patient was receiving physical therapy. There is no evidence of an order for these services in chart. In order to correct, an order was entered into chart.

Upon patient record review 1 of 23 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: The initial care plan indicates that a Physical therapy plan of care will be established and the SN to collaborate with physical therapy to meet patient needs. There is no evidence of collaboration or of follow up with physical therapy. There is no evidence of evaluation by physical therapy in the patient chart.

Upon patient record review, 1 of 23 (Patient #5,#10) did not have evidence in the patient record that hospice aide assignments and duties 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 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#5: The aide plan of care indicated patient was on seizure precautions. This was an error as patient does not require seizure precautions. In order to correct on site, seizure precautions were removed from the aide plan of care. Patient#10: The aide plan of care indicates aide to assist with feeding. However, there is no evidence of dietary requirements to meet patient needs. The patient is ordered honey thickened liquids and pureed foods fed with syringe. In order to correct on site, the plan of care was updated with ordered diet.

Upon patient record review 1 of 23 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: There is no aide visit documented since 6/12/25 to present. There is no aide visit documented the week of 5/11. Frequency order indicates aide to visit 1 time per week.

Upon observation, there was no evidence the annual report documents the 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. The 2024 annual report indicates volunteer use was 1.01%.

Upon patient record review, 2 of 23 (Patient #9,#13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#9: The record indicates the Addendum was elected to be received on EOB for benefit period starting 07/29/24. The record does not indicate when the addendum was furnished to the patient. The record indicates the addendum was signed as received on 11/04/24. Patient#13: The record indicates the Addendum was elected to be received on EOB for benefit period starting 01/09/25. The record does not indicate when the addendum was furnished to the patient.

Upon patient record review, 1 of 23 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1: The record indicates that physician filled out the State of Virginia DNR verbal order form indicating that the patient had previously indicated her wishes in writing in advanced directives. There is no evidence of advanced directives in the patient record. The agency was able to obtain the advanced directives and upload them during survey.

Upon patient record review, 12 of 23 (Patient #1,#2,#3,#5,#6,#7,#11,#12,#13,#14,#16,#18) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1,#2,#3,#5,#6,#7,#11,#12,#13,#14,#16,#18: The record indicates patient has Medicare as primary payor source, which is indicated on the agency EOB. However, there is also a state Medicaid EOB form completed in the patient chart. There is no indication the patient has Medicaid.

Upon personnel record review, 1 of 16 (Personnel #7) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #7: There is no evidence of the MSW serving as an advisor for the BSW after January 2025.

Based on a review of the agencys complaint log, interviews and agency complaint policy, it was determined the agency failed to ensure to protect the patient caregiver's right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant for one (1) of one (1) clinical record in the survey sample (Clinical record for Patient #1). --- Findings The agency's complaint log was reviewed in the agency on October 22, 2024. The agency's complaint log contained a complaint regarding Patient #1 by the complainant via phone call on April 25, 2024 at 3:30 PM regarding care of Patient #1. The complaint log indicated the complaint was received as a phone call and Staff Members #2 and #5 spoke to the complainant. The complaint itself was then emailed to hospices legal and compliance team and was advised to not contact the complainant but allow (previous hospice) to respond. The complaint log indicated outcome/results: Complainant continued to call and was informed that (previous hospice) will reach out to her regarding the complaint. On October 23, 2024 at 10:27 AM, The Medical Facilities Inspector interviewed Staff Member #9, via phone call, whom revealed the new hospice has not reached out to the complainant because this could be a legal issue but we did pass this along to the previous hospice. Staff Member #9 was unable to reveal who and when the complaint was passed to the previous hospice. The complainant was called via telephone on October 22, 2024 at 1:20 PM. The complainant revealed no one has reached out regarding the complaint. On October 22, 2024, the agencys (previous hospice) admission packet contained the title ";Complaint" page 6 that indicated you will be able to voice grievances regarding treatment of care that is (or fails to be) furnished. Your complaint will be investigated and the agency will document both the existence of the complaint and the resolution of the complaint. The complaint log review, interviews, and agency procedures failed to exercise the rights to voice grievances with an investigation and resolution.

Based on a review of clinical records and a review of agency Interdisciplinary group (IDG) procedure, it was determined the agency failed to ensure the ongoing sharing of information between all disciplines providing care for one (1) of one (1) patient in the survey sample (Patient #1). Specifically, the agency staff failed to coordinate and document the patients caregivers level of understanding, conflicting views of hospice care, and agreement with the plan of care, in accordance with the hospices own policies. --- Findings: The clinical record for Patient #1 was reviewed for the period of January 21, 2023 through September 15, 2023. The clinical record indicated an on-going issue with the patient and their two (2) children with conflicting views of hospice care as follows: -April 05, 2023-The Medical Social Worker (MSW) indicated the patient discussed butting heads with their child (complainant) because the (complainant) wants to do things their way and doesnt consider the patients feelings. The patient reported giving up Physical Therapy but the complainant feels that the patient should continue. The MSW spoke with the complainant following the patient visit and complainant reported that the patient has been mean to them. -May 31, 2023-The MSW indicated the complainant feels the patient is on too many medications which causes the patient to be more lethargic and reports she and (name redacted-other child) cannot agree on patients medications and feels the patient may be allergic to Haldol but the (other child) goes behind her back. The MSW offered to be a mediator for the two (2) children but the complainant declined. The MSW indicated reporting this visits concerns to the Registered Nurse Case Manager (RNCM) -(Staff Member #1). -June 12, 2023- Skilled Nurse (SN) indicated the hired caregivers report patients increased agitation but the patients child (complainant) is reducing the patients Haldol. Education given to the complainant regarding the situation but complainant persistent on reducing the patients medications. -September 13, 2023, the clinical record indicated a visit that was held as a meeting to develop a plan of care to ensure Patient #1 is receiving appropriate care with medication for comfort. The visit consisted of Staff Members #1, #3 and 16, two (2) hired caregivers and the two (2) children of the patients with a son-in-law present. The clinical record indicated much arguing between the patients two (2) children. One child (complainant) felt that patient is overmedicated and the other child feels that the patients comfort is important and medical professionals advise should be taken. The complainant also felt medications were being hidden and other medications being provided inappropriately. A medication log was agreed upon to be completed by the RNCM, Staff Member #1 as a remedy. -August 07, 2023-SN indicated disease progression education of the patient to the child (complainant) but complainant denies disease progression and states ";she is drugged". -August 14, 2023-SN indicated patients hired caregivers reports patients agitation and screaming is an on-going issue. SN educated patients child (complainant) regarding symptom management and medications. The complainant reports I dont want the patient drugged up and believed diet will resolve symptoms. -August 27, 2023-SN indicated a bottle of liquid Ativan was found in the home by the complainant that was not prescribed by the patients physician. The SN advised the complainant to dispose of this medication and use the liquid Ativan prescribed by the patients physician. There appears to be some level of discord among family members regarding medication management of the patient and has been on-going. The above clinical record notes indicated a meeting on September 13, 2023 due to conflicting views of hospice care by the patients two (2) children. The patient was transferred to another hospice agency September 15, 2023. On October 23, 2024, the agencys policy titled ";INTERDISCIPLINARY GROUP AND GROUP MEETING" with the date of May 2023 indicated as follows: 8. Documentation of patient/caregiver issues and needs discussed during the IDG are recorded on the IDG. The agencys IDG failed to document the on-going patient/caregivers issues for the time period of January 21, 2023 through September 15, 2023.

Upon patient record review, 3 of 16 (Patient #8, 9, 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #8- The medication profile included oxygen use at night. SN visit note dated 6/27/22 included continuous oxygen use with ambulation. The medication profile did not include the continuous oxygen. Patient #9- RN visit note dated 5/6/22 contained documentation of use of intermittent O2. The oxygen was not included on the med profile. RN visit note dated 5/16/22 contained documentation of increasing O2 to 6LPM via NC. The oxygen change was not included on the med profile. Patient #11- Wound care order dated 5/9/22 included application of Medihoney. The wound healed and wound care discontinued on 5/23/22 however Medihoney was not discontinued on 5/23/22 when wound healed- it was not discontinued on the medication profile until 7/8/22.

Upon patient record review, 2 of 16 (Patient #1, 15) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1- The patient SOC date was 11/19/21 and the initial bereavement assessment was not completed until 11/26/21 which is outside of the 5 day requirement. Patient #15- The patient SOC date was 5/14/22 and there is no evidence of an initial bereavement assessment to date.

Upon patient record review, 3 of 16 (Patient #5, 8, 11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #5- The 5/9/22 nursing soc note identified a pleurex drain however the plan of care contains no goals or interventions related to the pleurex drain. Patient #8- The 5/30/22 plan of care includes a diagnosis of DM as well as both insulin and sliding scale insulin with no associated goals and interventions related to the care and management of DM. Patient #11- The 6/5/22 and 6/3/22 nursing visit notes include documentation of patient with 16Fr Foley inserted on 5/22/22 however plan of care does not include associated goals or interventions to date.

Upon patient record review, 6 of 16 (Patient #1, 8, 9, 11, 14, 15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- The 6/21/22 and the 6/28/22 wound care orders contain no wound location. Patient #8- The plan of care includes orders for oxygen at night however the nursing documentation on 6/27/22 states patient has continuous O2 with ambulation. Patient #9- The RN visit note dated 5/6/22 included documentation of intermittent oxygen use. There was no evidence of an order for oxygen until 7/8/22. RN visit note dated 5/16/22 included documentation of patient's oxygen being increased to 6LPM. There is no evidence of an order for the oxygen change. Patient #11- The 5/9/22 wound care order read facility staff to change 2xweek and prn with no qualifier. Patient #14- The 5/27/22 POC reads wound care as ordered with no specific detail on the wound care to be performed. Patient #15- The 5/14/22 wound care order contains no frequency to date.

Upon patient record review, 2 of 16 (Patient #4. 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #4- The 7/1/22 plan of care does not include all DME as the patient has a wheelchair according to the nurses documentation on 7/7/22 and per surveyors observation during home visit. Patient #9- The 5/6/22 plan of care reads no DME- however the patient has had oxygen and a walker since the 5/6/22 nursing soc assessment .

Upon patient record review, 2 of 16 (Patient #5, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5- SN visit note dated 5/15/22 indicated that 1000 cc fluid was drained from the pleurex drain. There were no orders related to the care and management of the pleurex drain. Patient #11- The nursing note dated 5/4/22 included documentation of Zinc being applied to stage 1 sacral wound. There was no evidence of an order in the record for use of zinc.

Upon patient record review, 1 of 16 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties 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 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6- The 6/20/22 aide care plan has a prn frequency for the task of laundry.

Upon patient record review 2 of 16 (Patient #2, 7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2- No care provided per aide visit note with no rationale. Patient #7- The current HHA care plan included Nail care to be completed the first visit of the week. Aide visit notes included documentation of nail care performed at each visit to date.

Upon patient record review, 10 of 16 (Patient #1, 5, 6, 8, 9, 10, 11, 12, 15, 16) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1- The 5/3/22 aide care plan created by the RN does not have credentials with the associated signature and date. Patient #5- The aide care plan and the physician order entered by the RN contains signature and date with no associated credentials. Patient #6- The 5/13/22 aide supervisory visit made by the RN contains no credentials with the associated signature and date. The visit notes 6/8/22-7/9/22 contain date with partial signature and with no associated credentials. Patient #8- The 6/28/22 and the 7/6/22 aide visits contain no associated credentials with the signature and date. Patient #9- The 6/21/22 and the 6/30/22 aide visits contain no associated credentials with the signature and date. Patient #10- The 6/29/22-7/7/22 aide visit notes contain no credentials with the associated signature and date. Patient #11- The 6/21/22-7/8/22 aide visits contain no associated credentials with the signature and date. Patient #12- The 4/16/22 nursing start of care assessment contains no credentials with the associated signature and date. Patient #15- The 5/18/22 and the 5/24/22 aide visits contain no associated credentials with the signature and date. Patient #16- The 5/23/22 aide visit contains no associated credentials with the signature and date.

Upon personnel record review, 1 of 16 (Personnel #3) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #3- The RN license on file expired 10/21/21.