Every finding on record at Grace Hospice of Virginia, LLC

It is required that the comprehensive assessment includes consideration of the following factors: the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included complete assessment details related to the patient's physical status. Clinical Record 2/Home Visit 2: The patient elected hospice care on 07/04/2024 with a diagnosis of alcoholic cirrhosis. During the home visit with the Medical Social Worker (MSW) [Personnel Record 2] on 01/21/2/25, the patient was observed to have a PleurX drain. The skilled nursing (SN) assessment dated 07/04/2024 documented that the patient had ascites and sometimes had as much as [sic] "500l" drained from his abdomen. The assessment did not indicate the type of drain or dates of drains. The SN recertification assessment dated 12/10/2024 did not document the presence of the PleurX drain. An as-needed (PRN) SN visit note dated 12/17/2024 documented that the "patient drain site internal stitches are on the outside and site appears to be infected." The visit note did not indicate that it was a PleurX drain. The assessment part of the visit note did not provide information related to the patient having a PleurX drain. The SN visit note dated 01/10/2025 documented that the patient reported that the dressing on the PleurX drain came off, and the nurse replaced it. The PleurX drain and site around the drain were not documented in the assessment part of the visit note dated 01/10/2025. In an interview on 01/21/2025, the Clinical Manager confirmed that the patient had a PleurX drain managed by the hospice agency. After a review of the clinical record and an interview with the Administrator and Clinical Manager, the Clinical Manager confirmed that the assessment did not include all of the required clinical assessment findings.

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) coordinated care and collaborated with the physician to ensure the implementation of the plan of care. Clinical Record 14: The patient elected hospice care on 10/14/2024 with a diagnosis of Alzheimer’s Disease. The patient was prescribed and using a Rivastigmine transdermal patch every day. The patient called the office on Friday, 10/25/2024, asking that a new prescription for Rivastigmine in a titrated dose be sent to the pharmacy. The patient’s caregiver called on (Saturday) 11/02/2024, complaining that she had been trying since Monday, 10/28/2024, to get her mother’s newly prescribed patch (Rivastigmine in a titrated dose). The coordination note dated 11/03/2024 documented, “Late entry from 11/02/2024. Received a call from triage regarding patient patches not being ordered as requested at Monday’s (10/28/2024) visit.” The coordination note dated 11/03/2024 documented that the caregiver called back on 11/03/2024, reporting that no one returned their call related to the patches on 11/02/2024. The Director of Clinical Services was informed of the ongoing concern on 11/02/2024. The Director of Clinical Services contacted multiple alternate pharmacies attempting to find the Rivastigmine patches in stock to provide for the patient. The Director of Clinical Services notified the patient on 11/03/2024 of all of the attempts made by the pharmacy to obtain the new dosage of the Rivastigmine patches timely for the patient. The caregiver stated that they requested the patches be ordered at the patient’s routine visit on Monday (10/28/2024). The caregiver stated they were informed that the patches were ordered and would be ready to be picked up, but the pharmacy reported they did not have the medication in stock. The caregiver continued to voice frustrations. The nurse provided active listening and emotional support until the caregiver hung up. The patient was transferred per request to an alternate hospice on 11/04/2024 after reporting a complaint related to the inability to obtain medication timely. There was no documented coordination of care and communication with the physician regarding the agency's inability to get the Rivastigmine in a titrated dose for the patient from the pharmacy.

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 14 (21%) clinical records reviewed, the agency did not ensure that the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected hospice care on 01/17/2025 with the diagnoses of Down syndrome and epilepsy. The patient was prescribed levetiracetam for seizures. The plan of care did not include documentation of seizure precautions. Clinical Record 8: The patient elected hospice care on 11/20/2024 with a diagnosis of malignant neoplasm of the brain. The SN assessment upon admission noted that the patient had had multiple seizures and was prescribed dexamethasone for cerebral edema and lacosamide and levetiracetam for seizures. The plan of care did not include documentation of seizure precautions. Clinical Record 9: The patient elected hospice care on 01/14/2025 with the diagnoses of multiple sclerosis and epilepsy. The plan of care ordered levetiracetam for seizures. The plan of care did not include documentation of seizure precautions. In an interview and chart review on 01/23/2024, the Corporate Quality Director confirmed the findings.

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, observation, and interview. In 2 of 14 (43%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatments necessary to meet the patient's needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 07/04/2024 with a diagnosis of alcoholic cirrhosis. During the home visit with the Medical Social Worker (MSW) [Personnel Record 2] on 01/21/2/25, the patient was observed to have a PleurX drain. The skilled nurse (SN) recertification assessment completed on 12/10/2024 for the certification period dated 12/31/2024 to 02/28/2025, documented that the patient had bilateral weeping legs. The SN nursing note dated 12/17/2024 documented that the patient had a PleurX drain. The plan of care dated 12/18/2024 for the certification period dated 12/31/2024 through 02/28/2024 did not include documentation of interventions to address the patient's bilateral weeping legs or the care and maintenance of the PleurX drain. The Clinical Manager confirmed in an interview on 1/21/2025 that the PleurX drain was managed by the hospice agency. Clinical Record 6: The patient elected hospice care on 01/09/2025 with a diagnosis of multiple sclerosis. The SN assessment dated 01/09/2025 documented that the patient had a suprapubic catheter. The plan of care dated 01/09/2025 ordered, "Nurse may insert 16 French (FR)-18Fr-/5-10cc bulb indwelling cath as needed (PRN) for bladder dysfunction. Change 1 time per month and PRN leaking" and "Hospice nurse to insert/maintain indwelling catheter 16FR/10 cc balloon. Change the catheter every 30 days or as needed. Hospice nurse for patient/caregiving/instructions/reinforcement of care of indwelling catheter." The plan of care contained no intervention for the care and maintenance of a suprapubic catheter. In an interview and chart review on 01/23/2024, the Corporate Quality Director confirmed the findings.

It is required that each patient’s individualized written plan of care medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 7 (29%) clinical records reviewed of patients with medical supplies, the agency did not ensure that all supplies were included in the plan of care. Clinical Record 2/Home Visit 2: The patient elected hospice care on 07/04/2024 with a diagnosis of alcoholic cirrhosis. During the home visit with the Medical Social Worker (MSW) [Personnel Record 2] on 01/21/2/25, the patient was observed to have a PleurX drain. The skilled nursing (SN) visit note dated 01/10/2025 documented that the patient reported the dressing on the PleurX drain came off, and the nurse replaced it. The PleurX drain and supplies were not documented on the patient's plan of care for the certification period dated 12/31/2024 through 02/28/2025. In an interview on 1/21/2025, the Clinical Manager confirmed that the patient had a PleurX drain managed by the hospice agency. Clinical Record 6: The patient elected hospice care on 01/09/2025 with a diagnosis of multiple sclerosis. The SN assessment dated 01/09/2025 documented that the patient had a suprapubic catheter. The plan of care dated 01/09/2025 ordered, "Nurse may insert 16 French (FR)-18Fr-/5-10cc bulb indwelling cath as needed/pro re nata (PRN) for bladder dysfunction. Change one (1) time per month and PRN leaking" and "Hospice nurse to insert/maintain indwelling catheter 16FR/10 cc balloon. Change the catheter every 30 days or as needed. Hospice nurse for patient/caregiving instructions/reinforcement of care of indwelling catheter." Catheter supplies were not included in the plan of care. In an interview on 01/22/2025, the Corporate Quality Director confirmed that the clinical records did not document catheter supplies, although there were catheter orders.

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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review. In 2 of 11 (18%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide care plan included written patient care instructions to meet the patient's needs. Clinical Record 2: The patient elected hospice care on 07/04/2024 with a diagnosis of alcoholic cirrhosis. The skilled nursing (SN) recertification assessment dated 12/10/2024 documented the patient had bilateral weeping legs. The SN visit note dated 12/17/2024 documented that the patient had a PleurX drain. The HA care plan, last updated on 10/24/2024, did not provide the HA with instructions addressing the patient's bilateral weeping legs and the PleurX drain. Clinical Record 6: The patient elected hospice care on 01/09/2025 with a diagnosis of multiple sclerosis. The SN initial assessment dated 01/09/2025 documented that the patient had a suprapubic catheter. The HA care plan developed by the Registered Nurse (RN) on 01/09/2025 assigned the HA the relevant task, "External catheter care." The HA care plan did not inform the HA that the patient had a suprapubic catheter.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interview. 2 of 13 (15%) record reviews, the written plan of care did not identify planned interventions based on problems identified in the updated comprehensive assessments. Record #39276: On 3/2/22 the RN completed a comprehensive assessment documenting the following problems of protein-calorie malnutrition, apnea, dysphagia, and episodes of aspiration and coughing. The plans of care orders dated and signed on 3/11/22 and 3/25/22 do not include planned interventions related to protein-calorie malnutrition, apnea, dysphagia, and episodes of aspiration and coughing. Record #48999: On 3/21/22 the RN completed a comprehensive assessment documenting the patient has toes amputated as the result of complications with diabetes and is on a diabetic diet. The plan of care order dated and signed 3/22/22 does not include any planned interventions related to diabetes. In an interview with the Administrator, the Administrator confirmed these findings.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by patient visit observation and interview. 2 of 3 (66%) observations during home visits the clinician did not follow the agency policy for bag technique. Record #30952: During a patient observation visit on 3/29/22 with a Skilled Nurse in a patient’s private residence, this surveyor witnessed the nurse place the medical equipment bag on the floor in the patient’s home. Record #96391: During a patient observation visit on 3/29/22 with the Hospice Aide in a skilled nursing facility, this surveyor witnessed the Hospice Aide place the medical equipment bag on the floor in the patient’s room. Agency Hospice policy #1002, titled Infection Control and Occupational Exposure to Bloodborne and Other Pathogens states, in part, “The bag shall not be placed on the floor (not even on a barrier). In an interview with the Administrator, she stated that she did not know why the staff did not follow safe handling of the equipment bags.