Every finding on record at Villa Blanca Hospice, Inc.

Observed in Record Review. In 1 of 11 patient records reviewed, Hospice surveyor noted for Home visit #1, the medical record did not contain an initial bereavement assessment. The chaplain stated that he thought the social worker was completing in and it was an oversight.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, Hospice surveyor noted the IDG care plan for home visit #1 had not been updated with wound care that was ordered and provided. The patient had two buttock wounds that did not appear as a problem on the care plan. This was confirmed by the Office Case Manager.

Observed in Record Review. Hospice surveyor noted for home visit #2, the clinical record did not contain the physician sign in for the IDG meeting held on 5/12/22. This was confirmed by the Office Case Manager. Observed in Record Review. In 3 of 11 patient records reviewed, Hospice surveyor noted for home visit #1, the clinical record was missing the sign in attendance for IDG. For example, the physician had not signed in for the 5/12/22 meeting. For home visit #3 the physician had not signed in attendance for the 5/12/22 and 5/26/22 IDG meetings.

Observed in Individual Tracer. In 1 of 1 tracers conducted, Hospice surveyor noted the hospice aide care plan did not include any information regarding two dressings the patient had on her buttocks as far as what the aide should do regarding showering the patient or what to report to the office regarding these dressings. The wound care had been in effect for several months and the aide care plan was not updated. This was confirmed by the Office Case Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, Hospice surveyor noted the medical record for home visit #1 did not include the specific dressing change for several nursing notes. For example, each nursing note stated dressing changed to buttocks per physician order the documentation did not include specifically what the dressing change was.

Observed in Document Review. Hospice surveyor noted the SNF contract did not contain:An agreement that it is the hospice’s responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF or ICF/IID resident were in his or her own home.

Observed in Document Review. Hospice surveyor noted the SNF contract did not contain: An agreement that it is the hospice’s responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF or ICF/IID resident were in his or her own home.

Observed in Document Review. Hospice surveyor noted the SNF contract did not contain: A delineation of the hospice’s responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions. Observed in Document Review. Hospice surveyor noted the SNF contract did not contain: A delineation of the hospice’s responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions.

Observed in Document Review. Hospice surveyor noted the SNF contract did not contain:A provision that the hospice may use the SNF/NF or ICF/IID nursing personnel where permitted by State law and as specified by the SNF/NF or ICF/IID to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care.

Observed in Document Review. Hospice surveyor noted the SNF contract did not include: A provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation.

Observed in Document Review. Hospice contracts for pharmacy, HME and SNF did not have a clause requiring criminal background checks. This was confirmed by the Office Case Manager.