Every finding on record at Vanguard Hospice Care, Inc.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness Binders on 02/13/2025 revealed the agency did not ensure that the emergency preparedness plan included a documented hospice-based and community-based risk assessment. During an interview on 02/13/2025, the Director of Patient Care Services stated, "We had one for 2019, but it hasn't been updated and can't locate it. We will complete a new one.” A review of the Emergency Preparedness Binders on 02/13/2025 revealed the agency did not ensure that the emergency preparedness plan included a documented hospice-based and community-based risk assessment.

It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness Binders on 02/13/2025 revealed the agency did not ensure to test the emergency preparedness plan annually between 06/01/2022-02/13/2025. During an interview on 02/13/2025, the Director of Patient Care Services agreed there was no documented evidence that the agency tested the emergency preparedness plan annually. Additionally, the DPCS stated, "Some of us did the shakedown last year but we do not have any documentation of it." A review of the Emergency Preparedness Binders on 02/13/2025 revealed the agency did not ensure to test the emergency preparedness plan annually between 06/01/2022-02/13/2025.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, it was revealed that the agency did not ensure that the initial comprehensive assessment was completed no later than five days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/12/2025. There was no documented evidence that an initial psychosocial assessment was completed or documented reason why. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/08/2022. The initial spiritual assessment was completed on 08/15/2022 (day 7, and 2 days outstanding). There was no documented evidence that an initial spiritual assessment was completed no later than five calendar days after the election of hospice care. There was no documented reason for the delay. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/15/2023. There was no documented evidence that an initial psychosocial assessment was completed or documented reason why. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/28/2022. There was no documented evidence that an initial psychosocial assessment was completed or documented reason why. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/17/2022. There was no documented evidence that an initial spiritual assessment was completed or documented reason why. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/13/2023. There was no documented evidence that an initial psychosocial assessment was completed or documented reason why. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services stated, "They should have been done in the first 5 days, but these weren't. I am not sure why."

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure that an initial bereavement assessment was completed. Agency Policy No. 9-023, Bereavement Services, stated in part, "A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice." CLINICAL RECORD 10: The patient elected the hospice benefit on 12/28/2022 and died on 01/14/2023. A post death bereavement assessment was completed on 01/16/2023. There was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/17/2022 and died on 09/23/2022. There was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/13/2023 and died on 08/11/2023. A post death bereavement assessment was completed on 08/12/2023. There was no documented evidence that an initial bereavement assessment was completed. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services stated, "They should have been done in the first 5 days, but these weren't. I am not sure why."

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes, reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires; no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that an update to the comprehensive assessment was completed and reviewed with the Interdisciplinary Group (IDG) at least every 15 days. Agency Policy No. 1-036, Interdisciplinary Group Meeting, stated in part, "The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes." CLINICAL RECORD 5: The patient elected the hospice benefit on 08/08/2022. The Registered Nurse completed a comprehensive assessment on 11/07/2022 and 02/02/2023. There was no documented evidence that a Registered Nurse visited the patient or completed an update to the comprehensive assessment between 11/08/2022 and 02/01/2023 (85 days). There was no documented evidence that an IDG Meeting was held between 10/22/2022 and 02/01/2023 (102 days) to review the plan of care or discuss the patient’s progress toward desired outcomes, or reassessment of the patient’s response to care. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that a Registered Nurse completed a comprehensive assessment between 11/08/2022-02/01/2023. The DPCS agreed there was no documented evidence of an IDG meeting to discuss this patient between 10/22/2022-02/01/2023. Additionally, the DPCS stated, "I am not sure why the RN did not see the patient during this time or why there is no IDG meeting documented. We have them every two weeks."

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 9 (11%) personnel records reviewed, it was revealed that the agency did not ensure personnel completed the annual in-service training in accordance with agency policy. Agency Policy No. 1-033, Training/Inservice Education, stated in part, "Annual in services will include, but not be limited to hospice philosophy, goals, and services, protection of patient and family/caregiver rights, including confidentiality (HIPAA), knowledge of Advance Directives and power of attorney, communication and documentation skills, interdisciplinary group approach to care with the registered nurse as care coordinator, physiological, psychosocial, and spiritual aspects of terminal care, protocols to deal with grievances and issues of ethical concern, respect for cultural diversity and special communication needs, bereavement care, family dynamics and crisis management, concepts of palliative versus curative care, procedures for responding to medical emergencies, processes for communicating with the hospice staff, on-call protocols, safety policies and procedures, infection control, establishing and maintaining professional boundaries with patient and family/caregiver, areas of potential conflict of interest, skills updates, medical device act, quality assessment performance improvement process. Personnel will receive notification of organization-sponsored programs at least one (1) week in advance. A record will be maintained for each session." PERSONNEL RECORD 5: The Social Worker was hired on 11/10/2022. In-services were completed on 11/10/2022. There was no documented evidence that in-services were completed annually in 2023, 2024 through 02/13/2025. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that the in-services were completed annually. Additionally, the DPCS stated, "She is coming in this weekend so we can get everything done that is missing."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed, in which a Licensed Vocational Nurse provided nursing services, revealed the agency did not ensure that the Licensed Vocational Nurse was supervised by a Registered Nurse. Agency Policy No. 1-031, Responsibilities/Supervision of Clinical Services, stated in part, "The Clinical Director/Director of Patient Care Services will assure that the following supervision is maintained within the organization: A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services." CLINICAL RECORD 5: The patient elected the hospice benefit on 08/08/2022. The Licensed Vocational Nurse (LVN) was visiting the patient weekly between 11/08/2022-02/01/2023. There was no documented evidence that a Registered Nurse (RN) visited the patient between 11/08/2022-02/01/2023. There was no documented evidence that a Registered Nurse supervised the Licensed Vocational Nursing services provided at least monthly between 11/08/2022-02/01/2023 (85 days). During a joint record review and interview on 02/13/2025, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that a Registered Nurse supervised nursing services provided by the LVN between 11/08/2022-02/01/2023. Additionally, the DPCS stated, "I was not aware an RN didn't visit or supervise the LVN for that period. The RN should go every 14 days. I have no explanation."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 7 (71%) clinical records reviewed, it was revealed that the agency did not ensure to provide bereavement services according to the bereavement plan of care and agency policy. Agency Policy No. 9-023, Bereavement Services, stated in part, "After a death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. After three (3) weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information copy of the patient referral and initial bereavement assessment, bereavement service report, all bereavement assessments made, a bereavement plan of care, all bereavement clinical notes that have been written and/or letters sent to the bereaved." CLINICAL RECORD 9: The patient elected the hospice benefit on 08/15/2023 and died on 08/24/2023. The bereavement plan of care ordered a bereavement mailing at 1 week, 1 month, and 12 months. There was no documented evidence that the bereavement mailing at 1 week, 1 month, and 12 months was sent to the bereaved. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/28/2022 and died on 01/14/2023. The bereavement plan of care ordered a bereavement mailing at 12 months. There was no documented evidence that the bereavement mailing at 12 months was sent to the bereaved. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/24/2023 and died on 03/01/2023. The bereavement plan of care ordered a bereavement mailing at 1 month, and 12 months. There was no documented evidence that the bereavement mailing at 1 month and 12 months was sent to the bereaved. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/17/2022 and died on 09/23/2022. There was no documented evidence that an initial or post death bereavement assessment was completed. There was no documented evidence that the family/caregiver needs were discussed at the interdisciplinary group meeting following death. There was no documented evidence that a bereavement plan of care was developed. There was no documented evidence that a bereavement letter was sent after three weeks to the bereaved giving support and outlining the hospice bereavement services. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/13/2023 and died on 08/11/2023. The bereavement plan of care ordered a bereavement mailing at 1 week, 1 month, and 12 months. There was no documented evidence that the bereavement mailing at 1 week, 1 month, and 12 months was sent to the bereaved. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services stated, "I have checked with the Office Assistant, and we don't have any evidence the mailings were sent. We aren't sure who was supposed to mail them since the last Office Assistant is no longer working here. We will fix this." During an interview on 02/13/2025, the Bereavement Coordinator stated, "I don't mail anything, the office does." Additionally, the Bereavement Coordinator stated, "If it's not in there (EMR), I don't have it anywhere else."

It is required that hospice aides are supervised by a registered nurse who makes 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, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 12 (8%) clinical records reviewed, in which a Hospice Aide provided services ordered by the IDG, it was revealed that the agency did not ensure that the Hospice Aide was supervised by a Registered Nurse. Agency Policy No. 1-031, Responsibilities/Supervision of Clinical Services, stated in part, "The Clinical Director/Director of Patient Care Services will assure that the following supervision is maintained within the organization: Hospice aide supervisory visits will be conducted on site at least every two (2) weeks by a hospice registered nurse." CLINICAL RECORD 5: The patient elected the hospice benefit on 08/08/2022. The Hospice Aide was visiting the patient weekly between 11/08/2022-02/01/2023. There was no documented evidence that a Registered Nurse visited the patient between 11/08/2022-02/01/2023. There was no documented evidence that a Registered Nurse supervised the Hospice Aide services provided at least every two weeks between 11/08/2022-02/01/2023 (85 days). During a joint record review and interview on 02/13/2025, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that a Registered Nurse supervised the care and services provided by the Hospice Aide between 11/08/2022-02/01/2023. Additionally, the DPCS stated, "I was not aware an RN didn't visit or supervise the aide for that period. The RN should go every 14 days. I have no explanation."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. The Volunteer Cost Savings Report for the period dated 01/01/2024-12/31/2024 revealed the agency did not ensure that that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The total documented volunteer hours for the 12-month period were 1.32%. During a joint review of the Volunteer Cost Savings Report on 02/12/2025, the Director of Patient Care Services (DPCS) agreed the hospice agency did not meet the minimum five percent cost savings requirement for 2024. During an interview on 02/12/2025, the Volunteer Coordinator stated, "We need to work on getting volunteers in the patient homes. I am working on getting more volunteers." A review of the Volunteer Cost Savings Report on 02/12/2025 for the period 01/01/2024-12/31/2024 revealed the agency did not ensure that that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the agency did not ensure to assess the competency of the Social Worker according to agency policy. Agency Policy No 1-002, Human Resources, stated in part, "Clinical competencies will be assessed during the orientation process and annually thereafter for professional and paraprofessional personnel providing direct patient care. Competency assessments will be documented and retained in the personnel file." PERSONNEL RECORD 5: The Social Worker was hired on 11/10/2022. There was no documented evidence of a competency, initial or annual, upon hire through 02/13/2025. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that a competency assessment was completed upon hire or annually. Additionally, the DPCS stated, "She is coming in this weekend so we can get everything done that is missing."

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and staff interview. 3 of 11 (27%) clinical records revealed the agency failed to meet the individualized visit frequency orders as established by the IDG. Record #88747 (election of benefit 3/11/2022), plan of care orders (effective March 11, 2022), for the following disciplines was not met: LVN visit frequency order was for two (2) times per week and there were no documented visits for the week of 3/11/2022; Volunteer visit frequency order was for one (1) visit per week and there were no documented visits for the week of 3/11/2022. Record #73591 (election of benefit 1/6/2022), plan of care orders (effective January 6, 2022), for the following disciplines was not met: LVN visit frequency order was for one (1) visit per week and there were no documented visits for the week of 1/6/2022. Record #60903 (election of benefit 3/11/2022), plan of care order (effective March 11, 2022), for the following disciplines was not met: LVN visit frequency order was for two (2)visits per week and there were no documented visits for the week of 3/11/2022. In an interview with the Director of Clinical Services (Staff ID #12462) and LVN/QA nurse (Staff ID #10637), on 3/16/2022, they stated the visit frequency orders for the RN and LVN are written as discipline specific and not combined in a skilled nursing visit frequency order. Director of Clinical Services acknowledged the visit frequency orders for the start of care week should have been modified for records #88747, #73591 and #60903, to accommodate the admission occurring at the end of the week.

It is required that a hospice aide provides services Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) the hospice agency failed to ensure that hospice aides provided services as ordered in the plan of care. Record #88747 (election of benefit 3/11/2022), plan of care orders (effective March 11, 2022), with hospice aide visit frequency order was for two (2) times per week. One visit was documented as made for the week of 3/11/2022. Record #73591 (election of benefit 1/6/2022), plan of care orders (effective January 6, 2022), with the hospice aide visit frequency order for one (1) visit per week beginning 1/6/2022. No visit was documented for the week of 1/6/2022. Record #60903 (election of benefit 3/11/2022), plan of care order (effective March 11, 2022), with the hospice aide visit frequency order for three (3) visits per week. There were no documented visits for the week of 3/11/2022. During interview on 3/16/2022, the Director of Clinical Services and the LVN/QA nurse agreed with the finding.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and staff interview. 11 of 11 (100%) clinical records revealed the agency was utilizing an election of benefit document which failed to include the required “Patient Notification of Non-covered Items, Services, and Drugs” addendum which became effective on October 1, 2020. The following records have an election of benefit form (EOB) that does not contain the required “Patient Notification of Non-covered Items, Services, and Drugs” addendum: Record #63436 (election of benefit 1/4/2021), Record #37830 (election of benefit 6/15/2021), Record #34691 (election of benefit 6/15/2021), Record #69356 (election of benefit 7/22/2021), Record #37219 (election of benefit 10/27/2021), Record #58917 (election of benefit 11/11/2021), Record #36566 (election of benefit 6/6/2021), Record #16553 (election of benefit 9/20/2021), Record #73591 (election of benefit 1/6/2021), Record #60903 (election of benefit 3/11/2022), Record #88747 (election of benefit 3/11/2022). An interview was conducted on 3/16/2022 with the Director of Clinical Services (Staff ID #12462), who stated she was unaware of the required elements and LVN/QA nurse (Staff ID #10637) produced copies of the EOB statement and addendum forms (provided by The Centers for Medicare & Medicaid Services (CMS)) and stated she was aware of the required changes but had not yet implemented them.

It is required that the organization policy and procedure state the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes: Documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications; an a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications; and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. This standard was not met as evidenced by document review and staff interview. The agency failed to instate a policy and procedure as required by 42 CFR §418.60 – Condition of Participation: Infection Control. Agency policy and procedure manual and the agency COVID-19 binders were reviewed and revealed that the agency did not have any established policies to meet the new infection control condition of participation (42 CFR §418.60) related to stating the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. During an interview conducted on 3/16/2022, the administrator (staff ID #33960), director of clinical services (staff ID #12462), and the LVN QA nurse (staff ID #10637) all verbalized that they were aware of the new regulations that CMS (Centers for Medicare and Medicaid Services) had published but they had not yet written an agency policy. The administrator confirmed and a review did find that 100% staff had been fully vaccinated.