Every finding on record at James River Home Health Care, LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records, document reviews, interviews and observations. 3 of 8 (37%) records reviewed for which a hospice aide was accepted revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record #4 was reviewed and identified the patient elected hospice care on 8/23/2022, with the diagnoses of Parkinson's Disease and dementia. The aide care plan dated 9/2/2022, assigned aide tasks included "tub/shower...ambulate with stand by assist... ambulate with assistive device." During the home visit (HV#5) conducted on 9/6/2022, the aide notified the site visitor that the patient received a bed bath, due to the patient’s decline the previous week. The aide stated the Registered Nurse was aware of the change in bath type. The aide care plan did not reflect the change to a bed bath. In addition, the patient had history of falls. The patient was transferred with two-person maximum assist from the bed to chair. The patient was not able to ambulate. During an interview with the administrator on 9/6/2022, the findings of the home visit were reviewed, and the aide care plan updated on 9/8/2022. Record #2 was reviewed and identified the patient elected hospice care on 7/21/2022. The plan of care documented the patient's diagnosis as senile degeneration of the brain and ordered hospice aide services "twice weekly." The hospice aide care plans dated 7/28/2022 and 8/29/2022, assigned the aide tasks included, "bed bath and tub/shower to be completed at every visit." A review of the completed aide visits dated 7/26/2022, 7/28/2022, 8/2/2022, 8/9/2022, 8/11/2022, 8/18/2022, 8/25/2022, 8/30/2022, and 9/6/2022, revealed both bath types were documented as completed. During an interview on 9/7/2022, the Administrator called the hospice aide, and the hospice aide stated the patient’s bath type provided was a shower. Record #5 was reviewed and identified the patient elected hospice care on 8/5/2022, with a diagnosis of prostate cancer. The aide care plan dated 8/5/2022, did not include a specific bath type. The aide care plan assignment documented "admission assessment defined patient is cognizant/functionally able can determine bath type... every visit." The Registered Nurse visit note dated 8/12/2022, documented the patient’s change in condition, including an exacerbation of respiratory distress, and mental status documented as "oriented to person and place, forgetful and confused." The patient continued to decline in condition and expired 8/29/2022. The aide care plan was not updated based on the reassessment of the patient's cognitive or functional decline. The agency's policy #PC.H25 "Hospice Aide/Home Attendant Assignments and Duties", stated in part, "hospice aide/home attendants services are assigned based on comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living and ordered by the IDG...and... the hospice RN responsible for supervising the Hospice Aide/Home Attendant and prepares written patient care instructions that are patient-specific and not generic."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 4 of 8 (50%) records reviewed of patients that accepted hospice aides revealed the hospice did not ensure the aide provided the services in accordance with the documented plan of care. Record #6 was reviewed and identified the patient elected hospice care on 7/19/2022. The plan of care documented the patient's diagnosis as "intracranial injury" and ordered hospice aide services with a visit frequency of twice weekly. The aide care plan updated on 7/21/2022, assigned the aide the task, "changing linens” to be completed at every visit. The aide documented the assigned task of changing linens as “not ordered this visit,” for the aide visits completed on 7/28/2022, 8/4/2022, 8/11/2022, 8/18/2022, 8/25/2022 and 9/1/2022. Record #0 was reviewed and identified the patient elected hospice care on 7/21/2022. The plan of care documented the patient's diagnoses as "senile degeneration of brain and confusion.” The hospice aide care plan dated 7/25/2022, assigned “bed bath at every visit.” The aide documented the assigned task of bed bath as not completed due to "patient preference, pt. had to use bed side commode and agreed to get washed up while sitting there", for the aide visit completed on 7/26/2022. The aide narrative documented "Pt. ADLS performed per care plan." There was no evidence the aide reported the assigned bath type as not completed to the registered nurse. Record #1 was reviewed and identified the patient elected hospice care on 6/30/2022. The plan of care documented the patient's diagnosis as "senile degeneration of brain" and ordered hospice aide services with a visit frequency of twice weekly. The aide care plan dated 7/5/2022, assigned the aide the task, "transferring patient bed/chair" to be completed at every visit. The aide documented the assigned task of transfer bed/chair as “not ordered this visit," for the aide visits completed on 7/5/2022, 7/7/2022, and 7/11/2022. There was no evidence the aide reported the assigned task as not completed to the registered nurse. The hospice aide care plan was updated on 7/15/2022 and reflected bedbound activity. Record #3 was reviewed and identified the patient elected hospice care on 7/21/2022. The plan of care documented the patient's diagnosis as "senile degeneration of brain." The hospice aide care plan dated 7/25/2022, assigned all tasks to be completed at every visit. The aide documented the assigned task of changing linens as “not ordered this visit,” for the aide visits completed on 7/28/2022, 8/4/2022, 8/11/2022, 8/18/2022, 8/25/2022 and 9/1/2022. In addition, the aide documented the assigned task of shampoo as “not ordered this visit,” for the aide visit completed on 9/1/2022. The agency's policy #PC.H25 "Hospice Aide/Home Attendant Assignments and Duties" stated in part, " hospice aide are assigned to specific patients by a hospice RN that is a member of the interdisciplinary group and follow written patient care instructions in providing care to assigned patients...Hospice aides are assigned based on the comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living and ordered by the IDG." During an interview on 9/7/2022, the Administrator confirmed the hospice aides did not follow the frequency of assigned tasks on the respective patient's plan of care during the joint record review.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records, document reviews, interviews and observations. 2 of 8 (25%) records reviewed of patient's receiving aide services revealed the agency did not ensure the aide reported changes in the patient's condition and needs to the registered nurse. Home Visit #0: During the home visit observation of bed bath performed by hospice aide on 9/6/2022, the patient grimaced and moaned when the hospice aide touched the patient's left lower extremity. The hospice aide appropriately paused performing care until pain subsided, then resumed care with assistance of private sitter. The clinical record review on 9/7/2022, revealed the hospice aide visit note dated 9/6/2022 was missing documentation of the patient's pain or reporting the pain to the registered nurse. The aide documented a tub/shower was completed on 9/7/2022 was inaccurate, since a bed bath was completed during the observed home visit. During an interview on 9/7/2022, the Administrator stated the registered nurse would be notified to follow up with the caregiver and patient in regards to the patient's pain. Record #2 was reviewed and identified the patient elected hospice care on 7/21/2022 with the diagnosis documented as senile degeneration of the brain. The aide care plan was dated 8/29/2022. The aide visit dated 9/1/2022 documented all assigned tasks as not completed due to patient refusal. The aide's narrative note documented "patient was asked several times staff even tried refused all ADL care visit today." There was no documentation that the registered nurse or supervisor was notified that all of the aide's assigned tasks were not completed The agency's policy #PC.H25 "Hospice Aide/Home Attendant Assignments and Duties" stated in part, " hospice aide...follow written patient care instructions in providing care to assigned patients. (6) The duties of the hospice aide may include...(h) reporting changes in the patient's condition and needs to a registered nurse. "

Upon patient record review 3 of 11 (Patient #3, 4, 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 #3: HHA Care Plan assigned shampoo 1x/week The HHA documented performing shampoo 7/8/22 and 7/9/22. Patient #4: HA frequency order 2x/wk. There was no visit documented the week of 6/13/22. HHA Care Plan assigned shampoo 1x/week. The HHA documented performing shampoo 5/9, 5/11; 6//6, 6/8; 6/20, 6/22. Patient #7: HA frequency ordered 3x/wk. The aide completed 2 visits the week of 2/27/22, 1 visit the week of 3/6/22, 2 visits the week of 3/13/22, and 1 visit the week of 3/20/22. No evidence of refusal of visits. HHA Care Plan assigned shampoo 1x/week. The HHA documented performing shampoo 3/1, 3/2, 3/16, 3/18.