Every finding on record at Personal Touch Hospice of VA, Inc.

Upon patient record review, 1 of 14 (Patients #1) did not contain evidence that the Hospice had 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 #1: The RN SOC assessment reflected that the patient had a pacemaker. This was not included on the POC.

Upon patient record review, 2 of 14 (Patient #7,8) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions; specifically including medications and treatments: Patient #7: The RN SOC assessment reflected that the patient had a 16F 10cc foley in place. The POC dated 10/08/25 to 01/05/26 contained only, "SN assess function of indwelling foley and drainage system." This is an incomplete order, as it does not include the foley size, balloon, who in the home will be providing monitoring and maintenance of such foley, and the produced urine. Patient #8: A verbal order was obtained on 10/10/25 for, "CPAP minimum/maximum pressure range of 10-20 cm, with heated humidifier, and full face mask". This treatment was not included on the IDG POC dated 11/07/25.

Upon patient record review, 1 of 14 (Patient #8) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment: Patient #8: The record reflects that this patient is on oxygen 2-4 lpm, continuous as needed for shortness of breath. This oxygen is not included on the most recent IDG POC dated 11/07/25.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #7: A Physical Therapy evaluation was ordered to be conducted between 10/10 and 10/15/25, and was completed on 10/15/25. A subsequent verbal order dated 10/16/25 ordered a PT visit frequency of 2x per week x2. Only one PT visit was made the week of 10/11 to 10/17/25.

Upon patient record review, 2 of 14 (Patients #13 and 14) did not contain evidence that the Hospice had offered Bereavement Counseling that included: Ensuring that the Bereavement services provided, followed the Bereavement Plan of Care, and reflected the identified needs of the bereaved: Patients #13 and 14: Date's of death were on 12/27/24 and 10/14/24 respectively. There was no documented evidence that the hospice had followed the bereavement POC, as there was no evidence of a 6-month mailing having been sent to these patients.

Upon personnel record review, 1 of 11 (Personnel #8) did not contain evidence that an Aide Skills Competency Evaluation had been conducted per CMS guidelines: Personnel #8: An aide skills competency evaluation was conducted between 10/16 and 10/20/25. However, the following skill(s) were not evaluated for while the aide was providing care to a patient or pseudo-patient: Reading and recording temperature, pulse, and respiration.

Upon patient record review 1 of 14 (Patient #10) did not contain evidence that the Hospice Aide had provided 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 #10: The 90-day SOC POC ordered aide visits at a frequency of 2x per week. There was only (1) aide visit made/documented the week of 10/04-10/10/25.

Upon patient record review 3 of 14 (Patients #2, 9, and 10) did not contain documented evidence that a Registered Nurse had 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 was meeting these patients' needs: Patient #2: The first documented aide visit was made on 10/31/2025. As of the date of survey 11/19/25 there had been no aide supervisory visits documented. Patient #9: The first documented aide visit was made on 10/16/2025. As of the date of survey 11/19/25 there had been no aide supervisory visits documented. Patient #10: Multiple aide visits were made between 10/16/25 and 11/19/25. As of the date of survey 11/20/25 there had been no aide supervisory visits documented.

Upon personnel and contract review, 1 of 2 (Alternate Medical Director) there was not evidence that the hospice had an employee or contracted individual, to fulfill the role(s) of both Medical Director and Alternate Medical Director. Upon interview with the Administrator, he reported that their Medical Director had resigned such position/role in 08/2025. At that time, the then Alternate Medical Director was re-contracted with to fulfil the Medical Director position; then leaving no one to fulfil the position/role of Alternate Medical Director. The Administrator reports that the hospice has been actively recruiting for this Alternate Medical Director position. This was corrected on-site.

Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that the Hospice had obtained, no later than 2 calendar days after Hospice care was initiated, an oral or written certification of the terminal illness by the Hospice Medical Director: Patient #4: SOC 07/30/25. The initial certification of terminal illness by the Medical Director had been dated by the physician as of 08/13/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was initiated.

Upon patient record review, 2 of 14 (Patients #4 and 6) did not contain evidence that before the recertification period for each patient, the Medical Director or Physician Designee had reviewed these patients' clinical information and provided written documentation that it is anticipated that these patients' life expectancy is 6 months or less: Patient #4: For the recertification period of 10/28-12/26/25, the hospice Medical Director or designee, had not completed the re-certification in a timely manner. The Medical Director had not dated his signature on this CTI form. Nor was there evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. Patient #6: For the recertification period of 03/17-05/15/25, the Medical Director had dated his signature on the CTI as 03/20/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 05/16-07/14/25, the Medical Director had dated his signature on the CTI as 06/06/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 07/15-09/12/25, the Medical Director had dated his signature on the CTI as 07/22/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 09/13-11/11/25, the Medical Director had not yet dated his signature on the CTI form, nor was there evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Discharge Summary included all CMS-required information: Patient #11: Discharged/Revoked 05/19/25. The DC Summary did not include the following content: The patient's current plan of care.

Upon patient record review, 2 of 13 (Patient #1, #11) 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 • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1 and #11 had orders and a plan of care which stated oxygen was in use however, there was no evidence of oxygen included on the medication profile.

Upon patient record review, 1 of 13 (Patient #9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #9: An assessment by the RN was completed on 9-15-22, 10-13-22, and 11-17-22, no evidence of a comprehensive assessment within 15 or 21 days per the PHE waiver.