Every finding on record at Village Care LLC

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 clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025. The initial plan of care dated 07/30/2025 included orders for once-a-month visits by both the Social Worker and Chaplain. The initial comprehensive assessment did not include documentation of a psychosocial assessment and a spiritual assessment. There was no documented evidence that the Social Worker and Chaplain completed the assessments as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/07/2025. The initial plan of care dated 04/07/2025 included an order for Social Worker visits once a month. The initial comprehensive assessment did not include documentation of a psychosocial assessment and there was no documented evidence that the Social Worker completed the assessment as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 09/17/2025. The initial plan of care dated 09/17/2025 included an order for once a month visit by the Social Worker. The initial comprehensive assessment did not include documentation of a psychosocial assessment completed within five calendar days of the patient’s election of benefit. The initial psychosocial assessment was dated 10/03/2025. The clinical record did not include documentation to explain the delay in completing the assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/08/2025. The initial plan of care dated 05/08/2025 included an order for once a month visit by the Chaplain. The initial comprehensive assessment did not include documentation of a spiritual assessment and there was no documented evidence that the Chaplain completed the assessment as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessment. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the Social Worker and Chaplain assessments were not completed as ordered in the initial plan of care. The Administrator acknowledged awareness of the issue and reported that a performance improvement plan is currently in place to address and correct the deficiency.

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, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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 observation and interview. In 1 of 14 (7%) home visit observations, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1: The patient elected the hospice benefit on 08/17/2023 with a primary diagnosis of Senile Degeneration of the Brain. During the home visit observation with the Home Health Aide (HHA) (Personnel Record 3), a medication review was completed by comparing the hospice medication profile to the patient's current home medications. Review of medications was completed with the patient’s paid caregiver. The patient’s current home medications included Rytary 23.75 mg three times daily and Rytary ER 36.25 mg four times daily. Rytary and Rytary ER were not listed on the patient’s current hospice medication drug profile and were not included in the medication review process. The caregiver, who has provided care for the past year, stated the patient has been on these medications throughout her time with the patient. Following a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that a long-term medication currently taken by the patient was not documented on the agency’s drug profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/17/2023. Clinical record review revealed the comprehensive assessment did not include an initial bereavement assessment. There was no documented evidence of an initial bereavement assessment that included an assessment of the needs of the patient’s family. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/29/2024. Clinical record review revealed the comprehensive assessment did not include an initial bereavement assessment. There was no documented evidence of an initial bereavement assessment that included an assessment of the needs of the patient’s family. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the initial bereavement assessments were not completed at admission.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients followed the individualized plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/07/2025. Review of the clinical record revealed that the initial plan of care, dated 04/07/2025, included an order for Medical Social Worker (MSW) visits once per month. The order was also carried forward on the two most recent recertification plans of care. However, as of the date of record review on 11/05/2025, the MSW had not documented that social service visits had been provided to the patient. There was no documentation in the clinical record that the patient had declined social service visits. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025. Review of the clinical record revealed that the initial plan of care, dated 07/30/2025, included orders for Medical Social Worker (MSW) and Chaplain visits once per month. These orders were also carried forward on the most recent recertification plan of care. However, as of the date of record review on 11/05/2025, the Social Worker and the Chaplain had not documented that visits were provided to the patient. There was no documentation in the clinical record that the patient had declined MSW or Chaplain services. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the frequency of services documented in both the initial and recertification plans of care was inaccurate. Additionally, there was no supporting documentation indicating that the patient or caregiver declined the ordered services. The Administrator stated that this issue had already been identified internally and that a new Performance Improvement Plan (PIP) has been implemented to address it.

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/IID (intermediate care facility/Individuals with Intellectual Disabilities) 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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who died while on hospice services, the agency did not ensure the bereavement plan of care was developed. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/18/2024 and subsequently passed away while receiving hospice services on 06/20/2024. A review of the clinical record revealed that although both pre- and post-bereavement assessments were completed and bereavement mailings were sent within the required timeframes, there was no documented bereavement plan of care outlining the specific bereavement services to be provided to the bereaved parties. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/10/2024 and subsequently passed away while receiving hospice services on 02/25/2024. A review of the clinical record revealed that although both pre- and post-bereavement assessments were completed and bereavement mailings were sent within the required timeframes, there was no documented bereavement plan of care outlining the specific bereavement services to be provided to the bereaved parties. During interviews with the Administrator and the Alternate Administrator confirmed that the Bereavement Coordinator was actively following up with bereaved individuals. However, they acknowledged that the Bereavement Coordinator was not developing individualized bereavement plans of care following the death of the hospice patients.

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, 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 12 (8%) clinical records reviewed with hospice aide service provided, the agency did not ensure the Registered Nurse completed a hospice aide supervisory visit no less frequently than every 14 days. CLINICAL RECORD 11: The patient elected the hospice benefit on 06/13/2024. Hospice aide services were ordered at a frequency of two times per week beginning on 06/13/2024. The patient was discharged on 07/18/2024. There was no documented evidence in the clinical record that an aide supervisory visit was completed by the Registered Nurse, a total of 34 days and 20 days outstanding. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed the record did not include documentation of a hospice aide supervisory visit that was completed during the patient's episode of care. They both acknowledged the oversight and agreed that the required supervisory visit had not been conducted.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 5 (100%) clinical records reviewed, the agency did not include medical supplies and/or DME provided by the agency to the patient on the written plans of care. Clinical Record 2: RN Initial Assessment dated 3/21/2022 documented DME needed and ordered was hospital bed, overbed table and oxygen concentrator and patient had walker and wheelchair. Medical supplies documented as provided were large gloves, large diapers, and wipes. Plan of care order dated 3/21/2022 for benefit period 3/21/2022-6/18/2022 did not document the DME and supplies provided by the agency. DME and supplies sections were blank. Clinical Record 1: RN Initial Assessment dated 3/20/2022 documented "medical supplies needed: will give large gloves, large diapers, wipes, chux, medical equipment. Ordered: bed, overbed table, APP mattress ordered." Physician order dated 3/20/2022 documented DME of hospital bed, over bed table and APP mattress were ordered. Plan of care order dated 3/20/2022 for benefit period 3/20/2022-6/17/2022 did not document medical supplies or DME provided by the agency. The DME and supplies sections were blank. Clinical Record 3: RN Initial Assessment dated 10/20/2022 documented "patient has new condom cath external 35 or 40 in place, patent and draining by gravity below bladder level," and under additional comments documented "medical supplies needed: wipes, chux, gloves." Plan of care order dated 10/20/2022 for benefit period 10/20/2022-1/17/2022 did not document medical supplies or condom catheter supplies provided by the agency. The supplies section was blank. Clinical Record 4: RN Initial Assessment dated 11/2/2022 documented "medical supplies needed: will give large gloves, large diapers, wipes, chux." Plan of care order dated 11/2/2022 for benefit period 11/2/2022- 1/30/2023 did not document the supplies provided by the agency. The supplies section was blank. Clinical Record 5: RN Initial Assessment dated 11/2/2022 documented "medical supplies needed: XLarge pullups, wipes, chux, gloves." Plan of care order dated 11/2/2022 for benefit period 11/2/2022- 1/30/2023 did not document the supplies provided by the agency. The supplies section was blank. Interview with the Director of Nursing on 11/30/2022 and 12/1/2022 confirmed the supplies and/or DME were missing from the plans of care during the joint record reviews.

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 physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 1 (100%) clinical record reviewed where the patient had an external catheter for incontinence treatment, the agency did not have documented physician orders for the external catheter. Clinical Record 3: RN Initial Assessment dated 10/20/2022 documented "patient has new condom cath external 35 or 40 in place, patent and draining by gravity below bladder level. Urine is yellow amber and sediment free. Will continue to monitor and change as appropriate." There was three (3) physician orders documented in the record. Two (2) physician orders, both dated 10/20/2022 documented GT Tube maintenance and the third (3rd) physician order dated 10/20/2022 documented the evaluation for hospice. There were no physician orders or plan of care orders for the external condom catheter and its maintenance. Interview with Director of Nursing on 12/1/2022 confirmed the physician order for the condom catheter was missing during the joint record review.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) discharge records reviewed for patients that were live discharges, the agency did not forward a copy of the hospice discharge summary to the receiving hospital facility. Clinical Record 2: A patient with Election of the Hospice Benefit dated 3/21/2022 and primary diagnosis of stage IV Myelofibrosis discharged from the hospice agency and was transferred to a local hospital. The Agency form titled, "Revocation of Election of Hospice Care" was signed by patient on 4/1/2022 and documented the reason as, "I wasn't feeling good last night and now I need to be seen. I am feeling like my stomach is going to blow up." A Hospice employee witnessed signature was present dated 4/1/2022. A clinical note titled Discharge Live dated 4/1/2022 documented by Registered Nurse (RN) stated the reason for discharge was due to patient moved out of hospice service area and patient elected to transfer to hospital. Discharge summary signed by same Registered Nurse dated 4/1/2022 documented reason for discharge as moved from service area and condition of discharge as dependent, admitted to hospital (non-contract) and patient's request/refusal/revocation of benefit. The RN documented "above physician notified of availability of DC summary" and physician made aware of discharge and summary faxed to MD. There was no documentation reviewed or provided that the discharge summary or patient information was sent to the receiving hospital facility for coordination and continuity of care by the agency. Clinical Record 1: A patient with Election of the Hospice Benefit dated 3/20/2022 and primary diagnosis of cerebral infarction discharged from the agency and transferred to a local hospital effective 3/22/2022. Agency form titled "Revocation of Election to Hospice Care" signed and dated 3/22/2022 by patient's representative (father) due to altered mental status of patient, documented the reason for revocation, "I went to wake my son this afternoon and he wouldn't wake up so I call 911. After they came he's going to go the emergency room with the ambulance." Agency RN signed as witness dated 3/22/2022. Discharge summary signed on 3/22/2022 by RN, documented "reason for discharge: Moved from service area," and under subtitle "Condition on Discharge" documented both admitted to hospital (non-contract) and patient's request/refusal/revocation of benefit. RN documented "above physician notified of availability of DC summary" and physician being made aware of DC and summary faxed to physician. There was no documentation of the discharge summary sent to the hospital by the agency for coordination or continuity of care. Interview with the Director of Nursing on 11/30/2022 confirmed the discharge summaries for Record 1 and Record 2 were not sent to hospital during the joint record review. The Director of Nursing stated that the agency's interpretation of the standard was if the discharge reason was a revocation, the discharge summary did not have to be sent to the receiving facility, but only for discharge reasons of transfers to hospice agencies.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by observation and interview. During a tour of the office medical supply storage area, the agency's medical supplies storage cabinet had expired supplies. During the inspection of the agency's medical supplies storage cabinet on 12/1/2022, it was revealed fourteen (14) sterile adhesive eye pads expired 6/1/2010 and a box of alcohol cleansing pads (30 pads) expired 06/01/2009. The Administrator witnessed the inspection and confirmed the supplies were expired. The supplies were removed and wasted from circulation by the Director of Nursing on 12/1/2022. During the inspection of the agency's medical supplies storage cabinet on 12/1/2022, it was revealed fourteen (14) sterile adhesive eye pads expired 6/1/2010 and a box of alcohol cleansing pads (30 pads) expired 06/01/2009. The Administrator witnessed the inspection and confirmed the supplies were expired. The supplies were removed and wasted from circulation by the Director of Nursing on 12/1/2022.