Every finding on record at Vantage Hospice LLC

It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.

It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.

It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.

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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical record review of patients that elected hospice services revealed the agency did not ensure that a registered nurse made an on-site visit to the patient's home to supervise the hospice aide was made no less frequently than every 14 days. CLINICAL RECORD 17: The clinical record review lacked evidence of and aide supervisory visit every 14 days in the benefit period 08/12/2025 to 10/10/2025. An aide supervisory visit was done on 08/14/2025 then 08/29/2025 (15 days). During a joint review of the clinical record with the Director of Nurses (Personnel Record 8) and the Administrator (Personnel Record 7) on 08/29/2025, they stated that the visit was changed due to the patient's request. Also, stated that they are looking at updating the process so that this does not happen in the future.

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 the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed revealed the agency did not ensure to update the plan of care with changes in the comprehensive assessment. CLINICAL RECORD 5: The patient’s election of benefit (EOB) was 01/27/2025 with a diagnosis of Alzheimer's Disease. On 08/19/2025, the nurse documented that the daughter was concerned about the patient's possible skin cancer. On 08/27/2025, the nurse documented that the patient had undergone a skin biopsy to the scalp 3 days prior, however, the plan of care was not updated with changes. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.

It is required that the hospice designates a member of each Interdisciplinary Group who is responsible for a patient/resident in a SNF/NF or ICF/IID. The designated IDG member provides overall coordination of care of the patient/resident, working with the facility representative staff. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical record review of patients in a facility revealed that the agency did not ensure there was coordination of care with the facility staff. CLINICAL RECORD 3: The patient’s election of the hospice benefit (EOB) was dated 06/04/2025 with a diagnosis of Alzheimer's Disease. The patient resided in a skilled nursing facility (SNF). There was no documented evidence as to the delineation of which agency (hospice or SNF) was to provide the wound care. There was a coordination of care form, however the wound care orders were not included and who was to perform the wound care was missing. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated that coordination of care is not present in the clinical record. They are aware of coordination with the hospice staff. They will be providing additional education to the clinical staff on documenting coordination with the facility.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 20 (15%) records reviewed revealed the agency did not ensure the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care Clinical Record 1: The patient elected hospice care on 10/07/2022. The social worker's initial assessment was completed on 10/13/2022, 6 days outstanding. During an interview on 11/15/2022, the Administrator confirmed the assessment was not completed in the required timeframe. Clinical Record 2: The patient elected hospice care on 03/01/2022. The chaplain completed the initial assessment on 05/19/2022, 79 days outstanding. During an interview on 11/15/2022, the Administrator confirmed the assessment was not completed in the required timeframe. Clinical Record 19: The patient elected hospice care on 05/28/2022. The chaplain completed the initial assessment on 06/03/2022,6 days outstanding. During an interview on 11/17/2022, the Administrator confirmed the assessment was not completed in the required timeframe.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 15 of 20 (75%) records reviews revealed the agency did not ensure the medication profile contained all prescriptions medications. The agency's policy, "Medication List and Monitoring" PC.17, reads 'list will include all prescription and OTC medications'. Clinical Record 6: The nursing visit note dated 10/27/2022, documented the patient was using "Oxygen at 2 LPM (liters per minute) intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 7: The nursing visit note dated 10/28/2022, documented the patient was using "Oxygen at 2-4 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 8: The nursing note dated 10/25/2022, documented the patient was using "Oxygen at 2 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 9: The nursing note dated 10/16/2022, documented the patient was using "Oxygen at 2 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 10: The nursing note dated 11/01/2022, documented the patient was using "Oxygen intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 11: The nursing note dated 3/21/2022, documented the patient was using "Oxygen at 2 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/16/2022. Clinical Record 12: The nursing note dated 5/11/2022, documented the patient was using "Oxygen at 2 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 13: The nursing note dated 09/27/2022, documented the patient was using "Oxygen at 8 LPM continuously per nasal canula. Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 14 The nursing note dated 10/15/2022, documented the patient was using "Oxygen at 4 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 15: The nursing note dated 4/5/2022, documented the patient was using "Oxygen at 2 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 16: The nursing note dated 1/03/2022, documented the patient was using "Oxygen intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 17: The nursing note dated 7/15/2022, documented the patient was using "Oxygen at 2 LPM continuously per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 18: The nursing note dated 6/16/2022, documented the patient was using "Oxygen at 4 LPM continuously per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 19: The nursing note dated 05/22/2022, documented the patient was using "Oxygen at 2-4 LPM intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. Clinical Record 20 The nursing note dated 8/23/2022, documented the patient was using "Oxygen intermittently per nasal canula." Oxygen was included on the physician signed plan of care, but was not documented on the medication profile as of 11/17/2022. During interview 11/17/2022 with the Administrator, stated after review of the records the medication profiles had not been updated with oxygen orders and were consequently corrected.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) records revealed the agency did not ensure the written plan of care was individualized to include interventions for problems identified on the initial and updated assessments.. Clinical Record 6: was reviewed and identified the patient elected hospice care on 8/5/2022. The plans of care dated 08/05/2022 and 11/03/2022 documented the patient's diagnosis of Diabetes, and the medications ordered to manage the Diabetes as well as an intervention that read "staff to monitor." The initial comprehensive assessment completed by the registered nurse on 08/05/2022, and the recertification assessment completed on 10/27/2022 indicated that blood sugar checks were being completed by the caregiver. There was no intervention for teaching and/or monitoring of the blood sugar included on the hospice plans of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) records reviewed revealed the agency did not ensure that the plan of care included all treatment orders. Clinical Record 10: was reviewed and identified the patient elected hospice care on 08/31/2022. The nursing visit note dated 11/08/2022 documented that a suprapubic Foley catheter dressing change was completed. There was no evidence of an order for the suprapubic Foley catheter dressing care as of 11/16/2022. The physician's orders dated: 08/31/2022 ordered ostomy bag "change every 3 days and as needed (PRN); and 09/01/2022 ordered suprapubic Foley change monthly and prn." The orders did not include the instructions for the "PRN" care of the catheter and ostomy. During an interview on 11/16/2022, the Administrator confirmed that the plan of care did not include completed treatment orders.

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/IDF (intermediate care facility/intellectual disability facility) 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 and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 5 (100%) records reviewed in which bereavement care was provided revealed the agency did not ensure the type of services and the frequency of services were included on the bereavement plan of care. Clinical Record 12: was reviewed and identified the patient elected hospice care on 01/25/2022. The patient expired on 06/01/2022. The post death risk assessment and the associated bereavement follow up were documented. There was no evidence of a bereavement plan of care created to date. Clinical Record 17: was reviewed and identified the patient elected hospice care on 06/24/2022. The patient expired on 08/20/2022. The post death risk assessment and the associated bereavement follow up were documented. There was no evidence of a bereavement plan of care created to date. Clinical Record 18: was reviewed and identified the patient elected hospice care on 05/11/2022. The patient expired on 06/18/2022. The post death risk assessment and the associated bereavement follow up were documented. There was no evidence of a bereavement plan of care created to date. Clinical Record 19: was reviewed and identified the patient elected hospice care on 05/28/2022. The patient expired on 06/07/2022. The post death risk assessment and the associated bereavement follow up were documented. There was no evidence of a bereavement plan of care created to date. Clinical Record 20: was reviewed and identified the patient elected hospice care on 04/11/2022. The patient expired on 08/27/2022. The post death risk assessment and the associated bereavement follow up were documented. There was no evidence of a bereavement plan of care created to date. During an interview on 11/17/2022, the Administrator and Bereavement Coordinator confirmed the finding and stated that a spread sheet was used to track care delivery post death bereavement assessment based on risk level identified, however there was no creation of a bereavement plan of care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 9 of 17 (53%) records reviewed of patients receiving hospice aide services revealed the agency did not ensure the hospice aide preformed the tasks ordered by the Interdisciplinary group (IDG) and included in the plan of care. Clinical Record 2: The aide care plan dated 09/13/2022 assigned the aide the task: shampoo one time per week. The aide documented the shampoo was provided during each visit completed on 10/31/2022 through 11/11/2022. During an interview on 11/15/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 3: The aide care plan dated 10/11/2022 assigned the aide the tasks: shower; shampoo; and foot care every visit. The aide did not document that the assigned tasks: shower; shampoo; and foot care were provided during the aide visit completed on 10/15/2022. During an interview on 11/15/2022, the Administrator confirmed that the aide did not follow the care plan. Clinical Record 4: The aide care plan dated 10/7/2022 assigned the aide the task: shampoo one time per week. The aide documented the shampoo was provided during each visit completed on 11/01/2022 through 11/11/2022. During an interview on 11/15/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 7: The aide care plan dated 10/7/2022 assigned the aide the task: shampoo to one time per week. The aide documented the shampoo was provided during each visit completed on 10/19/2022 through 10/14/2022. and 10/23/2022 through 11/11/2022. During an interview on 11/16/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 11: The aide care plan dated 03/7/2022 assigned the aide the task: shampoo one time per week. The aide documented the shampoo was provided during each visit completed on 03/21/2022 through 03/24/2022. During an interview on 11/16/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 12: The aide care plan dated 04/1/2022 assigned the aide the task: change bed linens every visit. The aide documentation did not support task completion of bed linen change on 05/30/2022. During an interview on 11/17/2022, the Administrator confirmed that bed linens were not changed during each visit as ordered. Clinical Record 13: The aide care plan dated 09/27/2022 assigned the aide the task: shampoo one time per week. The aide documented the shampoo was provided during each visit completed on 10/24/2022 – 10/28/2022. During an interview on 11/17/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 16: The aide care plan dated 11/30/2022 assigned the aide the task: shampoo one time per week. The aide documented the shampoo was provided during each visit completed on 12/20/2021 – 01/12/2022. During an interview on 11/17/2022, the Administrator confirmed that the shampoo was provided each visit and not as ordered. Clinical Record 18: The aide care plan dated 05/11/2022 assigned the aide the task: bath every visit. The aide did not document that the assigned tasks: bath was provide during the aide visit completed on 05/13/2022. During an interview on 11/17/2022, the Administrator confirmed that the bath was not provided every visit as ordered.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by a review of document reviews, interviews and personnel records. In 4 of 6 (67%) applicable records reviewed of unlicensed employees and/volunteers who have direct patient contact or access to patient records revealed the hospice did not ensure the criminal background checks were obtained in accordance with state requirements. The state licensing standard stated in part, "a Home and Community Support Services Agency (HCSSA) must conduct a criminal history check to determine whether an unlicensed applicant for employment has a conviction listed in the (State) Health and Safety Code ….., or whether the applicant is listed on the EMR as unemployable. Additional licensure standards for hospice agencies.... which reflect federal standards (42 CFR §418.114(d)), require a hospice to conduct a criminal history check on all hospice employees and volunteers (including licensed professionals) with direct client contact or access to client records. In addition to the initial verification of employability, the Licensing Standards … .require a HCSSA to search the EMR annually to determine whether an unlicensed employee or volunteer is listed as unemployable in either registry. The HCSSA should maintain a copy of the results of the annual search in the employee or volunteer’s personnel record. " Staff 7: Review of the personnel record of the volunteer coordinator hired on 6/6/22, and the EMR (Employee Misconduct Registry) binder revealed a missing initial EMR criminal history check. Following an interview with the Administrator on the missing EMR report, the hospice completed a cleared EMR search report on 11/17/22. Staff 6: Review of the personnel record of the spiritual counselor hired on 11/20/17, and the EMR binder revealed missing annual EMR criminal history checks for 2020 and 2021. Following an interview with the Administrator on the missing EMR reports, the hospice completed a cleared EMR search report on 11/17/22. Staff 8: Review of the personnel record of the volunteer hired on 9/1/22, and the EMR binder revealed a missing initial EMR criminal history check. Following an interview with the Administrator on the missing EMR report, the hospice completed a cleared EMR search report on 11/17/22. Staff 11: Review of the personnel record of the bereavement coordinator hired on 9/16/19, and the EMR binder revealed missing annual EMR criminal history checks for 2020 and 2021. Following an interview with the Administrator on the missing EMR reports, the hospice completed a cleared EMR search report on 11/17/22. During an interview on 11/15/22, the Administrator stated the EMR (Employee Misconduct Registry) confirmed the finding and stated the EMR search checks were not completed for the unlicensed spiritual counselor, bereavement counselor, volunteer coordinator and volunteers. During interview 11/15/22, the Administrator stated the EMR (Employee Misconduct Registry) search checks were completed initially and annually for the Hospice Aides, however the EMR search checks were not completed for the unlicensed spiritual counselor, bereavement counselor, volunteer coordinator and volunteers who have access to clinical records and/or make patient visits. (State) Licensing Standards at §97.247, a Home and Community Support Services Agency (HCSSA) must conduct a criminal history check to determine whether an unlicensed applicant for employment has a conviction listed in the (State) Health and Safety Code (THSC) §250.006, or whether the applicant is listed on the EMR as unemployable. Additional licensure standards for hospice agencies in §97.855, which reflect federal standards (42 CFR §418.114(d)), require a hospice to conduct a criminal history check on all hospice employees and volunteers (including licensed professionals) with direct client contact or access to client records. In addition to the initial verification of employability, the Licensing Standards at §97.247(a)(5) and THSC §250.003(d) require a HCSSA to search the EMR annually to determine whether an unlicensed employee or volunteer is listed as unemployable in either registry. The HCSSA should maintain a copy of the results of the annual search in the employee or volunteer’s personnel record.