Every finding on record at Legacy Visiting Nurse Association (VNA)

Observed in Record Review. In 2 of 12 patient records reviewed, The hospice did not conduct patient-specific comprehensive assessments and reassessments that identified the patient’s need for hospice care and service. The surveyor noted in two of eighteen active records wound assessments and reassessments were not performed. Examples: In NHV#5 a post surgical open foot wound (unable to be staged as residual from necrotizing fasciitis) was not assessed or reassessed despite ongoing treatment. In NHV#4 wound assessments were not performed for multiple wounds including heels, buttocks, coccyx and sacral area. Reviewed with Clinical Director.

Observed in Record Review. In 2 of 6 home visits conducted, The organization did not provide the patient with care, treatment, or services according to the patient's needs identified needs. The frequency of skilled nursing assessments the assessed on admission as one visit within each two week period was not not increased in response to changes in condition and need for symptom management in two records (HVRR#1 and HVRR#2). Examples: In record (HHRR#1) on a patient with end stage asthma with symptoms of anxiety, shortness of breath and nausea persisted through the first four weeks on service. The patient stated during the home visit that my symptoms are not managed. Prior to this visit the hospice had observed the patient on admission, and during two skilled assessments in a four-week period. During the same period of time ten triage calls were received symptom support. In addition to active symptoms a Stage I sacral ulcer assessed on admission as 1cm by 1cm had deteriorated to 8 by 10 cm's by the second visit approximately two weeks later and had not been reassessed for treatment effectiveness since. The patient presents with significant cachexia with boney prominences. In record (HHV#2) on patient with ES Multiple Sclerosis that pain and symptom management for nausea, constipation, pain and anxiety required many medication changes. During the last forty days of her life skilled nursing assessments were made in accordance to the initial frequency assessed on admission as one visit within each two week period; this was not changed despite receiving over twenty triage calls during the same period of time. It was noted on a clinical note the last week of life the caregiver stated on a Chaplain check in call can a nurse come and lay eyes on her. The patient experienced unresolved, persistent constipation issues as evidenced by not having a bowel movement for over two weeks in one period only to experience another delayed bowel movement of over a week again. Reviewed with Clinical Manager. Observed in Record Review. The organization did not obtain an order for an acupuncture treatment prior to performing the procedure. The surveyor noted this in one of eighteen active record reviews. Example: In NHV#12 a consult and treatment for an acupuncture treatment was not obtained. Reviewed with Director of Nursing.

Observed in Document Review. Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The surveyor noted during review of volunteer hours and through interview with the volunteer coordinator that the requirements were not met for the past three years. Examples: FY23 was 2.38%, FY24 3.4% and FY25 3.7%. This was confirmed by the Volunteer Coordinator and Leadership.

Observed in Record Review. In 3 of 16 records reviewed, orders were not specific to the care provided. On review of HSRR #9, it was noted that PT care was completed that did not have frequency ordered by the physician prior to providing care. On review of HSRR #12, PT provided services that were not ordered and signed by the physician. On review of HSRR#16, the ordered HHA services a generic order that did not have a frequency for care. This was discussed with the clinical manager who was present for the chart review.

Observed in Record Review. In 2 of 16 patient records reviewed, the plan of care was not revised to reflect patient's need. In HSRR #9, the surveyor noted the patient was identified to have a suction machine ordered in the home; however, the plan of care did not include interventions to address this identified need. In HSRR #11, the surveyor noted the patient was identified as having nebulizer and pulse oximeter ordered in the home for use; however, the plan of care did not include interventions to address this. This was reviewed and confirmed with the clinical manager who was present for the chart reviews.

Observed in Patient Home. In 1 out of 4 home visits conducted, standard precautions were not used to reduce the risk of infections. CDC guideline for Hand Hygiene states, Alcohol based hand sanitizer should be place on hands and rub hands together, cover all surfaces until hands feel dry and it should take around 20 seconds for this. During HSHV#2 the nurse was observed during the visit on several occasions to squirt hand sanitizer in her hands without providing rubbing, full hand coverage and allowing product drying before moving on to enter bag or patient care. This was discussed with the assistant nurse manager who was present during the visits and also with the director.

Observed in Record Review. In 5 out of 8 patient records reviewed that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During record review of HSHV #2, HSHV #3, HSRR #5, HSRR #8, and HS RR #13 the assigned tasks did not include specific instructions for the aide to follow. For example, instructing the aide on the specifics on fall risk with patients that had frequent or high fall risk, instructing the aide to report change in skin condition to the RN on patients with frequent skin tears or that were bed bound and at risk for breakdown, and instructing on when to use a shower or bed bath when both are on the aide care plan. This finding was reviewed and validated with the Clinical Manager who was present for the chart reviews.

Observed in Patient Home. In 1 of 4 home visit conducted, the nurse surveyor noted that the organization had not reassessed medications of the patient. On HHHV #2, a patient had Bisacodyl and Refresh eye drops that was discontinued on the Hospice medication list however, the Assisted Living Facility MAR was not revised to reflect this changed. These medications were dated at the facility being on the record for over a month and agency policy is to do a medication reconciliation on each routine visit. This was reviewed and validated with the Assistant Manager who was present for the visit.