Every finding on record at Intrepid of Virginia, Inc.

Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon patient record review 2 of 13 (Patient #9, 12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient # 9: Admitted 2-10-22. Spiritual Assessment by SC was done 2/23/22. RN assessment did not meet standard for spiritual assessment. Patient #12: Admitted 3-11-22. Spiritual Assessment by SC was done 3/21/22. RN assessment did not meet standard for spiritual assessment.

Upon patient record review 3 of 13 (Patient #3, 9, 12) 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 #3 Admitted 5/26/22. MSW made phone calls to family to schedule visit, but no answer. There was no evidence of MSW visit or a psychosocial assessment. Patient #9: Admitted 2-10-22. No MSW visit was documented. There was no evidence that a psychosocial assessment was performed. Patient #12: Admitted 3-11-22. No MSW visit documented. There was no evidence that a psychosocial assessment was performed.

Upon patient record review, 2 of 13 (Patient #9, 12) 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 #9: Patient admitted 2/10/22. Bereavement assessment completed 2/23/22. Patient #12: Patient admitted 3/11/22. Bereavement assessment completed 3/21/22.

Upon client record review, 3 of 13 (Patient #2, 3, 8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #2: SOC 5/18/22. First documented IDG is 6/10/22, exceeding 15 days. Patient #3 SOC 5/26/22. First IDG 6/15/22, exceeding 15 days. Patient #8:SOC 5/13/22. First IDG not until 6/10/22, exceeding 15 days.

Upon patient record review, 3 of 13 (Patient #1, 9 and 10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1 SN 5/23/22 visit patient exhibited rash under breast and back. SN obtained order for Nystatin. IDG/POC was not updated to include interventions/goals regarding this change in condition. The rash persisted and Diflucan was ordered 6/17/22 based on SN assessment. Still the IDG/POC was not updated to include interventions/goals regarding ongoing symptom/problem. Patient #9: SOC 5/10/22. IDG 6/18/22 and subsequent meetings contain no documented explanation or discussion regarding no MSW visit/assessment performed. Patient #10 SOC 4/21/22: MSW documented that patient was sad that his wife had to provide care to him and that wife became tearful and left the room. (demonstrating need for psychosocial support). 4/29/22 IDG meeting and order with SW 1x/mo. 5/13/22 IDG Meeting note: MSW to help with LTC ins. No documentation of visits beyond initial visit 4/21/22. 6/10/22 IDG Meeting had no MSW freq. and no explanation.

Upon client record review, 2 of 13 (Patient #7, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: Admitted 9-15-21. Initial POC Order included MSW 1/month. Visits provided accordingly, until last visit made 11/2/21. It is not clear why MSW visits stopped. The frequency remained MSW 1/mo on IDG Meeting documentation until 5/13/22, although no visits were made, since 11/2/21. Patient #9: SOC 5/10/22, initial POC ordered SW eval within 5 days. No evidence of SW visit. IDG 6/18/22 and subsequent meetings contain no documented explanation or discussion regarding no MSW visit/assessment performed.

Upon patient record review, 2 of 11 applicable (Patients #1, 12) 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 #1: HA Assignment includes "Complete bed bath as requested" and "Partial Bath/Shower as requested." There are no statements regarding patient/cg cognitive ability to make requests. Patient #12: HA Assignment includes "Complete bed bath - Patient may choose. Complete Shower - Patient may choose." There are no statements regarding patient's cognitive ability to make choices.

Upon patient record review 1 of 11 applicable (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: aide care plan included "Shampoo every Thursday; change linen and make bed every Thursday." There were no HA visits made on Thursday from 5/18-6/21.

Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #7: There is no orientation checklist scanned into the electronic personnel file for the MSW.

Upon personnel record review, 2 of 14 (Personnel #7, 8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #7: MSW does not have documented skills competency assessment for MSW role scanned into electronic personnel record. Personnel #8: SC/BC does not have documented skills competency assessment for BC role scanned into electronic personnel record.

Upon patient client record review, 1 of 13 (Patient #3) 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 #3: 5/26/22 NP Face to Face visit narrative references "Stage IV of Right Foot, First Toe". Admitting SN and subsequent visiting nurses do not identify or reference this wound. They do reference left ankle wound, also referenced by NP. Nurse interview denies presence of toe wound.

Upon client record review, 3 of 3 applicable discharge records (Patient #11, 12, 13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients #11, 12, 13 have no documentation that copies of the discharge summary were sent to attending physician.