Every finding on record at New Century Hospice of Richmond, LLC

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was not evidence of a full-scale exercise that is community-based every two years

Upon patient record review 1 of 14 records (Patient #1) 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 #1: The patient was admitted on 4/19/24. The record revealed that the spiritual assessment was completed on 4/25/24 which is greater than the 5 day requirement.

Upon patient record review, 3 of 14 records (Patient #5,#6, #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: The medication profile contained Polyethylene Glycol, Mix 17 Gms with 80% of liquid. There was not evidence of an accurately specified diluent. Corrected on site. Patient #6: The medication profile contained Lidocaine topical patch. Apply 1 patch transdermal once daily for abdominal, hip and back pain. There was not evidence of a specific location. The box at the patient's home and the verbal response from the patient indicated that she was applying 3 patches at one time to her areas of joint pain as needed. Corrected on site. In addition, the Hospice medication profile contained Vitamin D3, which the patient indicated that she was not taking. Patient #8: The MAR at the ALF indicated that Hyoscyamine 0.125 SL 4x/day as needed. This medication was not included on the hospice MAR.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: There was not evidence of an assessment of the wound at visits from the date of the initiation of the wound care order. Agency policy indicated that wounds are to be assessed at least weekly.

Upon patient record review, 2 of 14 records (Patient #8,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #8: The patient was admitted with a diagnosis of cerebral atherosclerosis. She was unsteady on her feet, had several falls, weight loss, was disoriented, had visual and auditory hallucinations and illusions, and did not always recognize her husband. There was not evidence that the plan of care reflected patient/family goals and interventions based on the neurological problems identified in assessments. Corrected on site. Patient #9: The patient was on Eliquis 5mg bid. There was not evidence of bleeding precautions in the plan of care. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #9: The initial orders for the social worker and the spiritual care counselor were 1 prn for an evaluation.

Upon patient record review, 4 of 14 records (Patient #4,#5,#6,#8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: The patient had an Aspira drainage system. The record indicated that 1 liter of fluid was being drained during the day and 1 more liter most nights for a total of 2 liters per day. There was not evidence of an order to drain the catheter, how often to drain the catheter or the amount to drain at each session or per day. Corrected on site. Patient #5: The record contained an order for Polyethylene Glycol, Mix 17 Gms with 80% of liquid. There was not evidence of an accurately specified diluent. Corrected on site. Patient #6: The record contained an order for Lidocaine topical patch. Apply 1 patch transdermal once daily for abdominal, hip and back pain. There was not evidence of a specific location. Corrected on site. Patient #8: The MAR at the ALF indicated that Hyoscyamine 0.125 SL 4x/day as needed. This medication was not included on the hospice MAR, and there was not evidence of an order. Corrected on site

Upon patient record review, 1 of 14 records (Patient #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 #10: The plan of care contained goals and interventions specifically indicated for the spiritual care counselor and the social worker. The patient/representative declined these services as of December 2023, however these goals and interventions remained active and not resolved. Corrected on site.

Upon client record review, 4 of 14 records (Patient #1,#4,#6,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The record indicated for an evaluation by the volunteer coordinator (at the start of care). There was not evidence that this evaluation was conducted. Patient #4: The record indicated an order dated 7/2/24 for wound care to be performed on a drainage site 2x/week by the skilled nurse and 1x/week by the primary caregiver. There was not evidence that wound care was provided by the skilled nurse at any visit. Patient #6: The social work visit frequency was revised on 6/26/24 effective 6/1/24 to 1x/week. For the weeks of 6/30/24-7/6/24 and 6/7/24-6/13/24, there was not evidence of a visit. Patient #9: The record indicated for an evaluation by the volunteer coordinator (at the start of care). There was not evidence that this evaluation was conducted. In addition, the visit frequency for the skilled nurse dated 5/24/24 was 1x/week. For the week of 6/23/24-6/29/24, there were 2 visits conducted by a skilled nurse.

Upon observation, 1 of 3 observation visits (Patient #5) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5, Aide: After washing her hands in the patient's bathroom sink, the staff member was observed drying her hands with a towel that was hanging in the patient's bathroom.

Upon patient record review 2 of 14 records (Patient #5,#7) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #5: The aide visit frequency, effective 5/19/24 was revised to 5x/week. For the week of 6/30/24-7/6/24, the record indicated only 4 visits. Patient #7: The aide visit frequency was 1w1, 3w1, effective 5/26/24 while the patient was in respite. The record indicated only 3 visits (5/31/24, 6/3/24 and 6/5/24).

Upon patient record review 1 of 14 records (Patient #1) did not have evidence of documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: An aide supervisory visit was conducted on 5/16/24. There was not evidence of another aide supervisory visit until 6/6/24.

Upon observation, there was not evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Documentation revealed the volunteer percentage of usage for the year 2023 was 0.3%.

Upon patient client record review, 1 of 14 records (Patient #6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #6: The benefit election statement that was signed on admission (1/25/24) indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. This document was furnished on 2/1/24 which is greater than the required time frame.

Upon patient client record review, 1 of 14 records (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. Patient #3: The patient had an Advanced Directive (OOHDNR) dated 2/13/24. The IDG plan of care indicated that the patient was a Do Not Resuscitate. The IDG narrative by the social worker indicated that the patient was a full code from, 5/10/24 to current and documentation for the same time period by the spiritual care counselor indicated that the patient was a Full Code.

Upon client record review, 1 of 14 records (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management

Upon personnel record review, 1 of 10 records (Personnel #6) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.