Every finding on record at Vara Hospice LLC

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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure the drug profile contained the patient's current prescription medications. Clinical Record 3: The hospice election of benefit was dated 04/05/2023. The 05/05/2023 physician's order read 'Levaquin 500 mg qd x one dose then 250mg q48hrs x10 days'. At the time of the review Levaquin was listed as an active medication on the drug profile. During interview 08/31/2023, Administrator reviewed the associated record and stated the medication should have been discontinued at the end of the 10 days per physician's order and had since been updated.

It is required that that 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); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) records reviewed the agency did not ensure that care and services provided are in accordance with the plan of care. Clinical Record 1: The hospice election of benefits was dated 06/21/2023. The 06/21/2023 hospice plan of care included a frequency of '3xweek' for the nursing services. During the week of 08/14/2023 there was documented evidence visits made on 08/14/2023 and 08/16/2023 however no evidence of a third visit for that week. There was also no evidence of documented rationale for the missing visit. Clinical Record 2: The hospice election of benefits was dated 03/30/2023. The 06/28/2023 hospice plan of care included a frequency of '1xmonth' for the social work services (MSW). For the months of May and June 2023 there was no documented evidence of the completion of MSW visits and no explanation as to why care was not provided as ordered. Clinical Record 3: The hospice election of benefits was dated 04/05/2023. The 04/05/2023 hospice plan of care included a frequency of '2xweek' for the nursing services. During the week of 05/08/2023 there was no documented evidence of the completion of nursing visits nor explanation of why care was not provided as ordered. For the week of 07/07/2023 and 08/02/2023 there was documented evidence of a nursing visits dated 07/07/2023 and 08/02/2023 however, there was no documented evidence of the completion of a second nursing visit for those weeks nor an explanation of why care was not provided as ordered. Clinical Record 4: The hospice election of benefits was dated 08/05/2023. The 08/05/2023 hospice plan of care included a frequency of '2xweek' for the nursing services. For the week of 08/05/2023 there was documented evidence of a nursing visits dated 08/05/2023 however, there was no documented evidence of the completion of a second nursing visit for that week nor an explanation of why care was not provided as ordered. During interview 08/31/2023, Administrator reviewed the associated records and stated missed visit documentation had not been entered and had since been corrected.

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 the detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure that the patient's individualized plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific needs of the patent. Clinical Record 3: The hospice election of benefits was dated 04/05/2023. The 08/03/2023 hospice plan of care included a Chaplain (SC) frequency of '0xmo, 1 prn'. The chaplain followed visits of 1 time per month to provide spiritual support and services. THe prn order lacked specificity on the criteria for the prn visit. During interview 08/31/2023, Administrator reviewed the associated record and stated that the frequency of 1xmo had inadvertently been omitted from the hospice plan of care and had since been corrected.

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 the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure that the individualized written plan of care included all treatments necessary to meet the needs of the patient. Clinical Record 7: The hospice election of benefits was dated 06/08/2023. The comprehensive assessment completed by the registered nurse on 06/08/2023 and included documentation that the patient had a 14 fr foley catheter, a nasogastric tube for bolus feedings as well as a sacral wound. The 06/08/2023 hospice plan of care did not show evidence of orders for the care of the catheter or the nasogastric tube. The wound care read 'large wound 10X14X4cm, pack with betadine-soaked gauze and secure'. The wound care order did not include the location of the wound or the frequency of the wound care. During interview 08/31/2023, Administrator reviewed the associated record and stated the orders were inadvertently omitted form the hospice plan of care and had since been updated.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) records reviewed the agency did not ensure that all entries in the patient record were appropriately authenticated and dated by the person performing the care/service. Clinical Record 2: The aide signature for all documented visits dated 06/30/2023 through 08/11/2023 contained no credentials. Clinical Record 7: The chaplain signature for visit documentation dated 06/13/2023 contained no credentials. Clinical Record 11: The aide signature for all documented visits dated 04/18/2023 through 05/30/2023 contained no credentials. Clinical Record 12: The Chaplain visit documentation dated 03/25/2023 and 04/12/2023 contained no credentials. The aide signature for all documented visits dated 03/34/2023 through 05/04/2023 contained no credentials. During interview 08/31/2023, Administrator reviewed the associated records and stated credentials were not present and had since been corrected.

It is required that If the hospice refers specimens for laboratory testing to a reference laboratory, the reference laboratory is currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements. This standard was not met as evidenced by interview. During review of the use of reference laboratory, the agency did not ensure the laboratory was currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements. The agency conducts laboratory waived testing. There was no documented evidence of a CLIA waiver. During interview 08/31/2023, Administrator stated was unaware of need to obtain CLIA for Clinical Pathology Labs Inc, and had since obtained required documentation. During review of the use of reference laboratory, the agency did not ensure the laboratory was currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements.