Every finding on record at Lake Sunapee Region VNA & Hospice

Based on interview and record review, it was determined that the facility failed to have a registered nurse (RN) assess the quality of care and services provided by the hospice aide and to ensure that services ordered met the patient/family needs no less frequently than every 14 days for 3 of 10 patients reviewed for supervisory visits. (Patient identifiers are #8, #10, and #11.)Findings include: --- Patient #11Review on 4/2/25 of Patient #11's "Hospice Plan of Care" for certification period of 1/31/25 to 4/30/25 revealed a physician's order for a Hospice Aide 3 times a week for 12 weeks starting 2/3/25.Review on 4/2/25 of Patient #11's RN visit notes revealed that there were no supervisory visits made from 2/18/25 through 3/9/25 (20 days).Interview on 4/2/25 at approximately 1:45 p.m. with Staff A (Chief Clinical Officer) confirmed the above findings.Review on 4/2/25 of the facility's policy "Hospice Aide Supervisory Visits" revised May 2022 revealed, "...1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days... 4. Supervisory visits and overall supervision will be documented in the clinical record..." Patient #8Review on 4/2/25 of Patient #8's "Hospice Plan of Care" for certification period of 3/6/25 to 6/3/25 revealed a physician's order for a Hospice Aide 2 times a week for 12 weeks starting on 3/9/25.Review on 4/2/25 of Patient #8's (RN) visit notes revealed that were no supervisory visits made from 3/6/25 through 4/2/25 (28 days). Interview on 4/2/25 at 1:30 p.m. with Staff A (Chief Clinical Officer) confirmed the above findings. Patient #10Review on 4/2/25 of Patient #10's "Hospice Plan of Care" for certification period of 1/29/25 to 4/28/25 revealed a physician's order for a Hospice Aide 2 times a week for 1 week, then 3 times a week for 13 weeks. Review on 4/2/25 of Patient #10's "Patient Care Order" revealed on 3/9/25 a new physician's order for a Hospice Aide 5 times a week for 7 weeks. Review on 4/2/25 of Patient #10's RN visit notes revealed that were no supervisory visits made from 2/5/25 through 3/26/25 (50 days).Interview on 4/2/25 at 1:30 p.m. with Staff A confirmed that the above findings.