Every finding on record at Hospice Vnsw/Wphc, Inc

It is required that the hospice maintains an emergency preparedness training program. The hospice EP training program includes the following for all new hospice employees and those providing services under arrangement: initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by personnel record review and interview. In 1 of 4 (25%) personnel records reviewed, the agency did not ensure that all new hospice employees received initial training in EP policies and procedures consistent with their expected roles. Personnel Record 11: A review of the personnel file for the Physical Therapist (PT) with date of hire (DOH) 8/1/22, revealed no evidence of initial training in Emergency Preparedness (EP) policies and procedures consistent with their expected role. During an interview on 12/21/23, the Administrator confirmed the finding and stated, the PT was hired and had an emergency which required a leave of absence. The EP training was not completed when the PT returned from the leave of absence.

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 interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. Clinical Record 3: The patient elected the hospice benefit on 3/4/21. In review of the clinical record for the benefit periods dated 9/10/23 to 11/8/23 and 11/9/23 to 1/7/24, it was revealed that the record included a medication order dated 3/4/21 for "Levemir 5-10 units PRN for DM, blood sugars over 200." However, the plan of care did not include any problems, goals, or interventions to address the patient's blood sugar. Clinical Record 12 / Home Visit 4: The patient elected the hospice benefit on 7/20/22 with a terminal diagnosis of Renal Failure. In review of the clinical record for benefit periods dated 9/13/23 to 11/11/23 and 11/12/23 to 1/10/24, it was revealed that a Registered Nurse (RN) conducted a routine visit on 11/29/23 and documented, "Increased peri-orbital edema." On 12/6/23, an RN conducted a routine visit and documented, "Peri-orbital edema remains. On 12/8/23, an RN conducted a routine visit and documented, “Anasarca noted with peri-orbital edema. Eyelids less swollen today." On 12/13/23, an RN conducted a routine visit and documented, “Bilateral lower leg soft pitting edema. Swelling of arms and hands, left greater than right. PCG reports swelling of hands was more pronounced the other day.” On 12/5/23 the interdisciplinary team (IDT) met, and documented an IDT summary which stated in part, "Last week had increased periorbital edema and lower leg edema." However, the plan of care did not include any problems, goals, or interventions to address the patient's edema and anasarca. A home visit observation was conducted with the home health aide on 12/20/23. It was observed that the patient had mild peri-orbital edema and hand swelling. The patient stated that the edema was improved and denied pain or discomfort. During an interview on 12/20/23, the Clinical Director and Patient Care Coordinator confirmed the findings.

It is required that the hospice provides an initial orientation for each employee. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by personnel record review and interview. In 1 of 4 (25%) personnel records reviewed, it was revealed that the agency did not ensure all new hospice employees received orientation on the hospice philosophy. Personnel Record 11: A review of the personnel record for the Physical Therapist (PT) with date of hire (DOH) 8/1/22, revealed there was no evidence that an orientation on hospice philosophy was provided upon hire. During an interview on 12/21/23, the Administrator confirmed the finding and stated, the PT was hired and had an emergency which required a leave of absence. Orientation was not completed when the PT returned from the leave of absence.