Every finding on record at V.N.A. Corporation

Based on document review and staff interview, the hospice failed to ensure that volunteers provided at least 5 percent of the total patient care and administrative service hours annually. This failed practice has the potential to affect quality of services for patients who request volunteer services. --- Findings include: Review of hospice volunteer documents included a spreadsheet for the volunteer hours completed for 2024. The spreadsheet showed the hours worked by hospice staff and volunteers for the first quarter of 2024 to be 3.3%, quarter 2 showed 3.9%, quarter 3 showed 2.9%, and quarter 4 showed no volunteer hours recorded. The overall percentage for 2024 was shown as 2.50%. During an interview on 03/13/25 at 1:40 PM, Staff A, Administrator, confirmed the hospice volunteer hours did not meet 5 percent of the total patient care and administrative service hours annually, and stated that there had been a turnover of the volunteer coordinator with the new one just starting on 03/01/25.

Based on record review and staff interview, the Hospice failed to send a discharge summary to the attending physician for 1 (Patient 11) of 2 live discharge patients and 2 (Patient 11 & 12) of 2 patients who revoked the election of hospice services. This failed practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. --- Findings Include: Review of Patient 11's clinical record showed a Start of Care date of 12/30/24 and a Certification Period from 12/30/24 to 02/24/25. Review of visit notes showed that on 02/24/25 the patient revoked services to go with a different hospice agency. There was no documentation to support a discharge summary had been sent to the physician or the new receiving hospice facility where care would continue. Review of Patient 12's clinical record showed a Start of Care date of 05/08/24 and a Certification Period from 01/03/25 to 03/03/25. Review of visit notes showed that on 02/12/25 the patient revoked services to go receive care at the hospital. There was no documentation to support a discharge summary had been sent to the receiving hospital facility where care would continue. During an interview on 03/13/25 at 2:35 PM, Staff A, Agency Administrator, confirmed the above findings of a discharged summary not being sent to the attending physician or to the receiving facilities for discharged hospice patients seeking continued health care services.

Upon patient record review, 2 of 11 (Patient #3, #9) 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. Patient #3: Miralax powder was listed on the medication profile but did not include the diluent instructions. COS Patient #9: Oxygen was listed on the medication profile without the route of administration. COS

Upon personnel record review, 1 of 11 (Personnel #9 ) did not have evidence of criminal background check being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #9: There was not evidence of a criminal background check in the record.