Every finding on record at Vienna Hospice and Palliative Care, Inc.

Observed in Emergency Management Session. The organization did not review and make necessary updates to the HVA and Emergency plan based on opportunities for improvement following a recent information technology outage. Example: The agency's electronic medical record platform (HospiceMD) experienced an outage lasting several days in the second week of May resulting in the agency activating its Emergency downtime procedures. The agency did not document the incident and create an after action report related to the actual event. Nor did the agency update their HVA to include technology outages as an assessed risk and their level of preparedness. At the time of this survey beginning 5/19/25, the agency is experiencing another HospiceMD outage. This was confirmed by Nursing Administrator.

Observed in Record Review. In 1 out of 10 records reviewed, the organization did not provide a detailed statement of scope and frequency of services necessary to meet the specific patient and family needs. Example: In RRHV#4, SN 2 times per week PRN visits did not include an indication for when to initiate the order. This was confirmed by the Nursing Administrator.

Observed in Record Review. The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. Example: In RRNHV#4, the hospice nurse performed an additional visit in week 3 of benefit period 2 that was not approved by the IDG. This was confirmed by the Nursing Administrator.

Observed in Record Review. In 1 out of 10 record reviews, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home every 14 days. Example: In RRHV#3, an aide supervisory visit was not done within the appropriate timeframes in week 5 of benefit period 14. The Aide Supervisory visit was done 4 days late. This was confirmed by the Nursing Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the RN did not visit did not visit at least every 15 days. For example, in record review #2 it was noted that no RN visit was made between 4/5/22 and 5/3/22. This was confirmed by the QA staff.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that in record review #4 the CHHA visited twice during the first week of care however the orders were for once weekly visits. This was discussed with the QA staff member.

Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that the cleaning of equipment policy was not followed. For example, in home visit #3 the RN was observed cleaning her equipment with Lysol wipes and immediately placing them back into the nursing bag with gloved hands. Upon review of agency policy for Bag Technique it was noted that the equipment is to be cleaned with alcohol wipes and hands decontaminated prior to returning items to nursing bag. This was discussed with the DPCS who was present on the visit.

Observed in Record Review. In 1 of 3 patient records reviewed, where hospice aide services were provided it was noted that the supervisory visit did not occur at least every 14 days. For example, in record review #2 it was noted that no supervisory visit was made between 4/5/22 and 5/3/22. This was confirmed by the QA staff.