Every finding on record at Sentara Home Care Services

Upon patient record review, 6 of 19 (Patient ##3, #4, #9, #12, #14, #17) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. #3, #4, #9, #12, #14, #17-The was no evidence of an initial bereavement assessment completed within the 5 days after SOC.

Upon patient record review 2 of 19 (Patient #5,#17) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5 and 17: The comprehensive assessment does not contain evidence of assessing the patient's Spiritual Care needs.

Upon patient record review, 9 of 19 (Patient #1,#3,#9,#10,#13,#14,#15,#16,#17) 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: Patient 1: The Medication Profile contains Morphine Sulfate 20mg/ml take 5mg po every 3 hours prn. There is no evidence of the dosing in ml and this is how family was provided medication. Corrected on site. Patient 3: The medication profile contains Norco 5-325mg 1-2 tabs po every 6 hours prn pain. There is no evidence of directive when to take 1 vs 2 tabs. Corrected on site. Patient 9: The medication profile contains Diazepam 2mg po tabs, Instill 2mg into tube every 6 hours prn. May give 2mg in a 5mg/ml solution if liquid indications. No clear instructions on dosing in mg or ml. Norco 5-325 1-2 tabs po Q4 hours prn pain, no evidence of when to take 1 vs 2 tabs. Haloperidol 2mg/ml instill 1mg into tube every 6 hours prn nausea, no evidence of how many ml's to give. Corrected on site. Patient 10: The medication profile contains Haloperidol 2mg/ml take 1mg po Q6 hours prn nausea. There is no evidence of the dosing in ml. Corrected on site. Patient 13: The medication profile contains Haloperidol 2mg/ml take 1mg SL Q6 hours prn nausea. There is no evidence on how many ml to give. Morphine sulfate 100mg/ml take 0.25-1ml po every 3 hours prn. There is no evidence of when to take 0.25 or the 1ml. Corrected on site. Patient 14: Has Debrox in the home and is using, it is not on the medication profile. Pt's caregiver states she is not longer taking albuterol and does not have any in the home it remains on the medication profile. Corrected on site. Patient 15: The medication profile contains Miralax 17gm po daily, there is no evidence of a diluent. Patient 16: The medication profile contains Lorazepam 0.5mg take 1-2 tabs every 8 hours prn anxiety. Trazodone 50mg ½-1tab QHS. There is no directive when to take 1 vs 2 tabs for either medication. Both corrected on site. Patient 17: The medication profile contains Calcium PO take by mouth, no evidence of dosing or frequency. Haloperidol 2mg/ml dissolve 1mg SL Q6 hours prn, no evidence of clear instructions to dissolve into what and how much liquid.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 6 of 19 (Patient #1,#3,#9,#10,#13,#16) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1: The POC/med profile and medication profile contain Morphine Sulfate 20mg/ml take 5mg po every 3 hours prn. This patient is a home patient and there is no evidence of education regarding the dosing in ml. Patient 3: The POC contains Norco 5-325mg 1-2 tabs po every 6 hours prn pain. There is no evidence of nurse educating caregiver when to give 1 vs 2 tabs. Patient 9: The POC/med profile contains Haloperidol 2mg/ml instill 1mg into tube every 6 hours prn nausea, no education provided how many ml's to give. Patient 10: The POC/med profile contains Haloperidol 2mg/ml take 1mg po Q6 hours prn nausea. This patient is a home patient and there is no evidence of education regarding the dosing in ml. Patient 13: The POC contains the following: Haloperidol 2mg/ml take 1mg SL Q6 hours prn nausea. There is no evidence the caregiver was educated on how many ml to give. Morphine sulfate 100mg/ml take 0.25-1ml po every 3 hours prn. There is no evidence of instructions when to take 0.25 or the 1ml. Patient 16: The medication profile contains Lorazepam 0.5mg take 1-2 tabs every 8 hours prn anxiety. Trazodone 50mg ½-1tab QHS. There is no evidence the nurse educated the caregiver when to give the patient 1 vs 2 tabs for either medication.

Upon patient record review, 13 of 19 (Patient #1,#2,#3,#6,#8,#9,#10,#11,#13,#14,#15,#16,#17) 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 1: The Plan of Care contains Morphine Sulfate 20mg/ml take 5mg po every 3 hours prn. There is no evidence of the dosing in ml. Corrected on site. Patient 2: The POC contains: hyocosamine, Keppra, morphine sulfate, acetaminophen, Advair, apixaban, glycopyrrolate, sennosides, the medications are not on the facility MAR as ordered on hospice POC. The facility MAR contains Acetaminophen, Apixaban, glycopyrrolate, Keppra, morphine, sennasides only. Patient 3: The POC contains Norco 5-325mg 1-2 tabs po every 6 hours prn pain. There is no evidence of directive when to take 1 vs 2 tabs. The POC contains oxygen 2 liters per nasal cannula. The pt does not have O2 in the home and does not need oxygen. Corrected on site. Patient 6: There is evidence the patient is taking the following medications as they are listed on the medication profile, however; they are not on the POC: Balsam/Castor Oil, Clotrimazole Cream, Magnesium Oxide, Metoprolol tartrate. Corrected on site. Patient 8: The medical record contains a note by the nurse "Condom cath in place" There is no evidence of an order for a condom cath. There is evidence that the patient has a G tube but there is no evidence of orders for G tube site care. Patient 9: The plan of care contains Diazepam 2mg po tabs, instill 2mg into tube every 6 hours prn and may give 2mg in a 5mg/ml solution if liquid indications, no evidence of clear instructions on dosing in mg or ml. Norco 5-325 1-2 tabs po Q4 hours prn pain, no evidence when to give 1 vs 2 tabs. Haloperidol 2mg/ml instill 1mg into tube every 6 hours prn nausea, no evidence of how many ml's to give. The POC 3-23-23 contains the following: "Instruct on Vanco lab regimen" There is no evidence pt is on or has ever been on Vancomycin. "Instruct cg on checking placement, residuals, administration of tube feeding, use of pump, flushes and site care". There is no evidence of orders for the flush fluid, frequency, amount of flushes, rate of tube feedings, type of pump used, site care. Nursing note on 2-12-23 contains "O2 2 liters per nasal cannula". There is no evidence of an order for O2. The 2-12-23 note by nurse contains "slight perianal irritation due to diarrhea treatment with Desitin." There is no evidence of Desitin on the POC. Patient 10: The POC contains Haloperidol 2mg/ml take 1mg po Q6 hours prn nausea. There is no evidence of the dosing in ml. Corrected on site. Patient 11: The POC contains 2 different orders for Oxygen 2 liters per minute and 3 liters per minute per NC during exertion and sleep. Corrected on site. Patient 13: The POC contains the following: Haloperidol 2mg/ml take 1mg SL Q6 hours prn nausea. No evidence on how many ml to give. Morphine sulfate 100mg/ml take 0.25-1ml po every 3 hours prn. No evidence of when to take 0.25ml or 1ml. Upon home visit there was no bisacodyl or farxiga both are on POC. The POC contains hyoscyamine 0.125mg dissolve 1 tab under tongue 4 times daily. The bottle in the home says 4 times daily prn. Home visit pt not taking entresto but remains on POC. Corrected on site. Patient 14: Patient has several bottles of Barrier creams that are not listed on the plan of care. Pt also has Debrox and Albuterol in the home and were ordered, caregiver states she is no longer taking these and does not have any in the home, no evidence of an order to discontinue these. The POC contains an order for a Foley with no directives for foley size, balloon size, or how often to change. Corrected on site. Patient 15: The POC contains Miralax 17gm po daily, there is no evidence of a diluent. Patient 16: The POC contains Lorazepam 0.5mg take 1-2 tabs every 8 hours prn anxiety. Trazodone 50mg ½-1tab QHS. There is no directive when to take 1 vs 2 tabs for either medication. Patient 17: The medication profile contains Calcium PO take by mouth, no evidence of frequency or dose. Haloperidol 2mg/ml dissolve 1mg SL Q6 hours prn, no evidence of how to dissolve.

Upon patient record review, 4 of 19 (Patient #2,#9,#10,#13) 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 equipment and supply needs. Patient 2: Upon facility visit pt has a Geri chair in his room that is not included on the POC. Corrected on site. Patient 9: The medical record contains a note on 2-16-23 by the nurse that pt has a Hoyer Lift. There is no evidence of this item on the POC. Corrected on site. Patient 10: The medical record contains a nursing note on 2-14-23 "she left her walker across the room." There is no evidence of this item on the patients POC. Corrected on site. Patient 13: Home visit finding, pt has a quad cane. There is no evidence of this item on the patients POC. Corrected on site.

Upon client record review, 4 of 19 (Patient #7,#10,#13,#17) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 7,10,13,17: The medical records contain evidence the patients chose a personal doctor as their attending. There is evidence of a CTI from the attendings. There is no evidence the hospice interdisciplinary group is collaborating with the individuals' attending physicians regarding changes that have taken place since the initial assessment.

Upon client record review, 6 of 19 (Patient #7,#8,#9,#11,#13,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The Plan of Care contains interventions for vital signs to be assessed every visit. There was a nursing visit on 3-23-23 with no evidence of vital signs being assessed. Patient 8: The medical record contains evidence of a missed visit by the RN on 3-29-23. There is no evidence of a refusal for the visit. Nurse note on 2-28-23 "wound covered abrasion to nose" and on 3-1-23 "dressing in place to nose". There is no evidence of an order for wound care to the patient's nose. Patient 9: Nursing note on 2-12-23 "Foley in place", and on 2-18-23 "Old Foley removed and new Foley placed." There is no evidence of an order for a Foley. Patient 11: Nurse documents in the medical record "cleansed left lower leg wound with wound wash and applied Optifoam." The POC order states to apply barrier cream to wound site and peri wound prior to applying Optifoam. The nurse documents in the medical record on 4-9-23 "skin tear to LLE cleansed with dwc and covered with Optifoam. There is no evidence of an order for the wound care. Patient 13: The plan of care contains interventions for cardiac and respiratory assessments every visit. There is no evidence the nurse performed these interventions on 4-11-23. Patient 14: The medical record contains a note by the nurse on 4-4-23 morphine 0.25ml was given to pt, the POC has orders for 0.5ml.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 10: The medical record contains a note by the nurse that pt had a fall on 3-6-23. There is no evidence of an incident report completed.

Upon patient record review 6 of 19 (Patient #2,#3,#4,#11,#13,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The medical record contains evidence of a missed visit by the aide the week of 4-2--4-8-23. There is no evidence of missed visit documentation. The aide plan of care contains assist with elimination, assist facial shave, assist oral care, change bed linens there is no evidence the aide completed those interventions on 2-27-23 visit. The medical record contains an aide visit completed on 3-3-23 there is no evidence of documentation by the aide of what interventions were completed. The form was blank. On aide visits 3-6-23, 3-10-23,3-13-23,3-16-23 and subsequent visits through 4-10-23 the aide did not complete the following interventions ordered on the aide plan of care: change bed linens, assist with elimination, facial shave, oral care, shampoo, hair care. There is no documentation that the nurse was notified and no evidence of patient refusing. Patient 3: The medical record contains an aide visit completed on 2-28-23 there is no evidence of documentation by the aide of what interventions were completed. The form was blank. Aide visits 3-1-23,3-6-23,3-8-23,3-14-23,3-17-23 with subsequent visits through 4-7-23 the aide did not document completing the following interventions: change linen, assist with elimination, apply lotion, oral care, shampoo hair. There is no documentation that the nurse was notified and no evidence of patient refusing. Patient 4: The medical record contains evidence of an aide missed visit the week of 4-2-23--4-8-23 with no documentation of pt refusal or communication with RN. There are aide visits documented on 3-28-23 and 3-30-23 where the aide did not complete the ordered interventions of change linens, oral care, apply lotion. On 4-4-23 the aide did not document completing ordered change linens, apply lotion, oral care and inspect skin. On 3-9-23 the aide did not document completing the ordered interventions of changing linens, dressing pt and oral care. There is a completed aide visit on 3-2-23 in the medical record that no interventions are selected as completed. The form was blank. There is no documentation that the nurse was notified and no evidence of patient refusing on any of the above missed interventions. Patient 11: The medical record contains Aide visits on 2-28-23, 3-2-23,3-7-23 there was no documentation, the form was blank. There is no documentation that the nurse was notified and no evidence of patient refusing. Patient 13: The medical record contains an aide visit on 3-24-23, there was no documentation, the form was blank. Patient 14: The medical record contains aide visits on 3-22-23 where the aide did not perform interventions of apply lotion, powder, ointments, oral care, dressing. There is a visit on 3-24-23 there is no documentation, the form is blank. The visit 4-5-23 the aide did not complete oral care. There is no documentation of why the aide did not complete any of the ordered interventions.

Upon patient client record review, 1 of 19 (Patient #9) did not have evidence that each patient record contains: Patient 9: The assignment of benefits page has no evidence of a date the patient signed the form. The date line is blank.

Upon patient client record review, 5 of 19 (Patient #1,#2,#9,#14,#17) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The medical record contains an abbreviation "MASD". There is no evidence this is an approved abbreviation. Patient 2: The Plan of Care contains orders for PT,OT, SLP. Upon speaking with the nurse, these were entered in error. The patient did not receive nor was ordered PT,OT,SLP. Corrected on site. Patient 9: The POC on 3-23-23 the nurse documents "Develop pMP with patient and family". There is no evidence pMP is an approved abbreviation. Patient 14: The POC on 6-29-22 contains PT, OT, SLP orders. Upon speaking with the nurse, these were entered in error. The patient did not receive nor was ordered PT,OT,SLP. Patient 17: The medical record contains a note by the RN "Nurse pronouncing death Heidi Albrecht NP". There is no evidence of Heidi Albrecht making a visit during the death and in the state of VA the RN can pronounce death.

Upon client record review, 2 of 19 (Patient #15,#16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patients 15 and 16: The medical record does not contain evidence of a copy of the hospice discharge summary was forwarded to the patient's attending physician.

Upon client record review, 2 of 19 (Patient #15,#16) did not have evidence that the discharge summary includes all required information. Patients 15 and 16: The medical record does not contain evidence of the discharge summary including: the patients current plan of care, treatments, symptoms or pain management, latest physician orders or any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility