Every finding on record at Venarks Hospice Inc

Upon patient record review 3 of 14 (Patient #1,#5,#13) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: There was no evidence of a psychosocial assessment completed within 5 days. The first documented psychosocial assessment was 02-24-25. Patient #5: The patient was admitted on 07-01-25 and there was no spiritual assessment completed until 07-08-25 which is greater than 5 days. Patient #13: There was no evidence of a psychosocial assessment within 5 days of the admission.

Upon patient record review 1 of 14 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 #10: The patient signed the Medicare Hospice Election and was informed of her rights on 08-07-25. The Elections for hospice care documented a start date of 08-14-25. However, the Chaplain made an initial visit to the patient on 08-13-25 and there was no evidence of spiritual assessment after start date of 08-14-25.

Upon patient record review 7 of 14 (Patient #1,#3,#5,#6,#7,#8,#10) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: MiraLAX 17gm per scoop was listed on the medication profile without evidence of a diluent. Patient #3: Melatonin by mouth was on the medication profile but written as "0" times a day. Additionally, Mupirocin and Zinc Oxide were on the medication profile, but without evidence of a route of application. Patient #5: Tizanidine and Polyethylene glycol were listed on the medication profile as PRN, but there were no reasons for the PRN listed. Patient #6: An order for O2 2-5 L via NC was on the initial plan of care, but there was no evidence it was added to the medication profile. Patient #7: Zinc oxide was on the medication profile without a route of application. Additionally, the initial plan of care indicated oxygen was ordered, but there was no evidence it was listed on the medication profile. Patient #8: Zinc oxide was listed on the plan of care without evidence of a route. Additionally, an order for oxygen 2-5 L per NC was on the initial plan of care, without evidence of it being listed on the medication profile. Patient #10: Oxygen was ordered on the initial plan of care, but there was no evidence it was added to the medication profile.

Upon patient record review, 1 of 14 (Patient #5) 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. Patient #5: There was no evidence of a bereavement assessment completed until 07-08-25 which is greater than 5 days after the admission date of 07-01-25.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10: On 08-14-25 there were orders for the SN to visit 1 x week for wound care, and the family to provide wound care on the other days. The SN visited on 08-18-25, but there as no evidence of a wound care assessment.

Upon patient record review, 4 of 14 (Patient #1,#8,#9,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient's terminal illness was heart failure, but there was no evidence of a care plan for Cardiac related goals or interventions. Patient #8: The patient's terminal illness was Senile Degeneration, but there was no evidence of goals or interventions related to Neuro on the care plan. Patient #9: The patient's terminal diagnosis was Heart failure, but there was no evidence of cardiac related goals or interventions listed on the care plan. Patient #10: The patient's terminal diagnosis was Alzheimer's, but there was no evidence of Neuro related goals or interventions listed on the care plan.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: Tizanidine and Polyethylene glycol were ordered as PRN, but there were no reasons for the PRN listed.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: The plan of care dated 08-18-25 included interventions to assess edema and grade, encourage elevation and instruct in use of diuretics. However, there were no diuretics ordered or listed on the medication profile and there was no location of edema identified on the plan of care or throughout the assessments.

Upon client record review, 1 of 14 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10: On 08-14-25 there were orders for the SN to visit 1 x week for wound care, and the family to provide wound care on the other days. The SN visited on 08-18-25, but there as no evidence of wound care provided.

Upon patient record review, 2 of 14 (Patient #6,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6:The aide plan of care frequency for the aide indicated 5 days a week and 1 PRN visit every 7 days. Patient #10: The aide plan of care frequency for the aide indicated 5 days a week and 1 PRN visit every 7 days.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: Aide visit note was signed and documented as a visit on 03-02-25 which was after the date of death of the patient. The comments section on the note indicated the visit was from 02-03-25 and the date had been transposed.

Upon patient record review, 2 of 5 (Patient #1, 4) 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 1: Medication profile entry on 03.17.2022 indicates Seroquel 150mg po bid; there is no dosing quantity for this medication - filed left blank. Additionally, the medication list indicates Miralax 17g po daily PRN constipation; there are no instructions for reconstitution. (corrected onsite) Patient 4: Medication list entry on 08.03.2022 indicates Miralax 17g po daily PRN constipation; there are no instructions for reconstitution.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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, 2, 3, 4, 5: The Initial Plans Of Care relating to medications were not signed by the physician. Current updates to the Plans of Care at the time of recertification were signed by the physician. However, the IPoC in the paper records were not signed by the physician relating to medications or the medication list.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 1, 2, 3, 4, 5: The Initial Plans Of Care relating to DME were not signed by the physician. Current updates to the Plans of Care at the time of recertification were signed by the physician. However, the IPoC in the paper records were not signed by the physician relating to DME.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 6 (Patient #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #5: The record did not contain evidence of the spiritual assessment completed within 5 calendar days after election.

Upon patient record review 3 of 6 (Patient #1, #2, #6) 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. Patients #1 and #6: There was no evidence that in the comprehensive assessment psychosocial needs were were assessed. Patient #2: There was no evidence that in the comprehensive assessment spiritual needs were assessed.

Upon patient record review, 5 of 6 (Patients #1, 2, 3, 5, 6) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1, 2, 3, 5 and 6: The IPOC contained an order for "laxative/enema of choice PRN" and lacked indicator for PRN use. Patient #6 had the following medications for acetaminophen on medication profile with no evidence of a maximum allowable dose [corrected on site]: 1. Tylenol 500 mg, take 1-2 tablets PO every 6 hours PRN for pain or fever. 2. Norco 5/325 mg, take 1 tablet PO every 4 hours PRN for pain. 3. Tylenol suppository 650 mg, 1 rectally every 4 hours PRN pain or fever.

Upon patient record review, 1 of 6 (Patient #5) 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. Patient #5: The record did not contain evidence that a bereavement assessment was completed within 5 days of election.

Upon patient record review, 2 of 6 (Patient #1 and 4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The record did not have evidence of advance directives (full code or DNR status) on face sheet, physician orders, comprehensive assessment, nor on plan of care. The record did not contain evidence of an update to plan of care after new order on 02/09/2022 to administer cefdinir 300mg tablet by mouth twice daily for 10 days for suspected UTI. Patient #4: order on 06/03/2022 for Macrobid 100mg 1 capsule twice daily for 7 days for suspected UTI however, there was no evidence in record of plan of care update. Last update to plan of care was on 05/07/2022.

Upon patient record review, 5 of 6 (Patient #1, #2, #3, #5, #6) 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, 2, 3, 5 and 6: The IPOC contained an order for "laxative/enema of choice PRN" and lacked indicator for PRN use. Patient #6 had the following orders for acetaminophen with no evidence of a maximum allowable dose [corrected on site]: 1. Tylenol 500 mg, take 1-2 tablets PO every 6 hours PRN for pain or fever. 2. Norco 5/325 mg, take 1 tablet PO every 4 hours PRN for pain. 3. Tylenol suppository 650 mg, 1 rectally every 4 hours PRN pain or fever.

Upon client record review, 1 of 6 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The order for nursing visit frequency was 1 per week and 2 PRN x 14 days however, the record showed evidence the week of 02/27 for a nurse visit on 02/27 and 03/04.

Condition of Participation: Infection Control.

Upon patient record review 1 of 3 applicable (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: The aide plan of care listed shave 2 times per week however, on the week of 01/23/2022 and the week of 01/30/2022 the aide shaved the patient on each visit (01/24, 01/26, 01/28, 01/31, 2/2, 2/4).

Upon patient client record review, 5 of 6 (Patient #1, 2, 3, 5, 6) 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. Patients #1, #2, #3, #5, #6: The record revealed on patient's initial certification by medical director that the benefit period dates were missing (signed 02/14/22, 03/17/22, 01/24/22, 03/27/22 and 01/24/22 respectively). [#5 and #6 were corrected on site] Patient's #5 and #6: The recertification CTI's did not have evidence of benefit period dates (signed 05/18/22 and 04/18/22 respectively). [corrected on site]

Upon personnel record review, 1 of 4 applicable (Personnel #3) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #3: The file did not have evidence that a criminal background had been obtained on this individual at time contract was initiated. [corrected on site]

Upon policy review the agency did not have evidence that the organization develops written policies and procedures to ensure that all personnel are fully vaccinated for COVID19. The policies and procedures include, at a minimum, the following components: ·A process for ensuring all personnel specified in 42 CFR 485.525(c)(1) (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of 42 CFR 486.525(c), or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to personnel providing any care, treatment, or other services for the organization and/or its patients; ·A process for ensuring that all personnel specified in 42 CFR 486.525(c)(1) are fully vaccinated, except for those personnel who have been granted exemptions to the vaccination requirements of 42 CFR 486.525(c) or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations. ·A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all personnel who are not fully vaccinated for COVID-19. ·A process for tracking and securely documenting the COVID-19 vaccination status of all personnel specified in 42 CFR 486.525(c)(1). ·A process for tracking and securely documenting the COVID-19 vaccination status of any personnel who have obtained any booster doses as recommended by CDC. ·A process by which personnel may request an exemption from the personnel COVID-19 vaccination requirements based on an applicable federal law. ·A process for tracking and securely documenting information provided by those personnel who have requested, and for whom the organization has granted, an exemption from the personnel COVID-19 vaccination requirements. ·A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines, and which supports personnel requests for medical exemptions from vaccination, has been 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 laws, and for further ensuring that such documentation contains: ·All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the personnel member to receive and the recognized clinical reasons for the contraindications; and ·A statement by the authenticating practitioner recommending that the personnel member be exempted from the HHA's COVID-19 vaccination requirements for personnel based on the recognized clinical contraindications. ·A process for ensuring the tracking and secure documentation of the vaccination status of personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and ·Contingency plans for personnel who are not fully vaccinated for COVID-19.