Every finding on record at Village Home Health LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the patient's plan of care reflected identified problems, patient-specific planned interventions, or patient/family goals developed from the updated comprehensive assessment findings. The agency policy entitled "Patient Assessments" (PE.1) and dated 01/01/2020, included in part that "... Updates to the comprehensive assessment will be accomplished by the IDG (Interdisciplinary Group) ... Changes that have taken place since the initial assessment or last comprehensive assessment, including the patient's progress toward desired outcomes, as well as the patient's response to care... Information from the updated comprehensive assessment will be used by the IDG to update the patient/family POC (plan of care) ..." The hospice's policy dated 12/01/2019 and entitled "Interdisciplinary Group Roles and Responsibilities" (PC.8) read in part that "The IDG ... will prepare a written plan of care for each patient/family, which specifies the care and services necessary to meet the patient/family-specific needs identified in the comprehensive assessment... A revised interdisciplinary POC will include information from the patient's updated comprehensive assessment and will note the patient's progress toward outcomes and goals specified in the POC..." Agency's policy "Review and Revision of Patient Care" (PC.9), dated 09/01/2015, included in part that "... Upon identifying that patient care needs have changed ... adjustments to the care planning documents will be made as follows IDT (Interdisciplinary Team) Plan of Care by RN, PT, OT, ST, MSW (Medical Social Worker), Counselor (Chaplain) ... Medication profile by RN ... Each change will be accompanied by specific interventions. All written changes to the plan of care will be incorporated into the patient's medical record as changes occur..." Clinical Record 5: The patient elected the hospice benefit on 12/09/2023 with the diagnosis of chronic obstructive pulmonary disease and resided in an assisted living facility. On 05/09/2024, an order was documented for Macrobid 100mg by mouth daily for urinary tract infection prophylaxis. In a Skilled Nurse Visit on 05/13/2024, the Registered Nurse (RN) noted in part that "... She is now on an antibiotic prophylactically to help her with UTIs as she was getting them very frequently ..." In the RN Recertification Assessment on 05/29/2024, it was noted in part that "... We added a medication to help prevent UTIs as she has had many in the past and her urine is darker. She frequently complains of cramping and not being able to go as frequently as she has been..." A review of the plan of care for the benefit period from 04/07/2024 to 06/05/2024 included an identified problem of bowel and bladder incontinence with one of the interventions to educate caregivers on the signs and symptoms of a urinary tract infection. There was no risk for infection problem identified and no patient-specific intervention regarding the use of a prophylactic antibiotic. The only goals were that the patient's incontinent bowel and bladder would be managed by the patient's caregivers and that the patient would maintain skin integrity. On 07/01/2024, the patient's plan of care was updated to include that the patient was at risk for infection related to a history of urinary tract infections. The goal was that the patient would remain free from symptoms of infection. From 05/09/2024 to 07/01/2024, the patient's plan of care was without the appropriately identified problem of recurrent urinary tract infections with patient-specific interventions or goals. Clinical Record 6: The patient elected the hospice benefit on 02/06/2024 with the diagnosis of chronic combined systolic and diastolic heart failure and resided in an assisted living facility. During a visit documented for 07/06/2024, the LVN/LPN made an extra visit as the agency was alerted to a patient's fall. The nurse noted in part that "... he is now trying to get out of bed several times within the last hour as he is having urgency and frequency and is very agitated. PRN visit made... At visit patient is still slightly uncomfortable and agitated needing to urinate... called (hospice physician) and he gave orders for antibiotic for UTI symptoms..." A physician's order was documented on 07/06/2024 for Keflex 500mg by mouth twice a day for a urinary tract infection..." The patient's plans of care for the benefit period from 05/06/2024 to 08/03/2024 included the identification of a problem of urinary incontinence, which included an intervention to educate the caregiver about the signs and symptoms of a urinary tract infection. No active infection problem was identified and no patient-specific interventions regarding the need for an antibiotic. The only goals were that the patient's incontinence would be managed by the caregivers and that the patient's skin would remain intact. The patient's plan of care was without the appropriately identified active infection, patient-specific interventions, or goals. After joint clinical record review and interview with the Director of Nursing (Personnel Record 2) and the Administrator (Personnel Record 1) on 08/14/2024, it was determined that the that the patient's plan of care did not include patient-specific problems, interventions, or the patient/family goals related to the identified high risk for infection or active infection findings that required new medications to be ordered for the patient.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 18 (11%) applicable clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that complete patient-specific instructions were provided to the aide in the aide care plan. Document 1: The hospice's policy dated 05/01/202 entitled "Delegation" (HR.27) read in part, "... the RN, in addition to the assessment relating to RN Assessment of the patient, will determine that the task does not require the unlicensed person to exercise nursing judgment ... Tasks prohibited from delegation... specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention...." The agency policy "Implementing Care and Treatment" (PC.7) dated 10/01/2020 included in part that "The hospice RN ... will oversee the assignment of a hospice aide to particular patient ... The aide will be provided with written instructions for patient care prepared by an RN ... " Clinical Record 8: The patient elected the hospice benefit on 04/08/2024 with the diagnosis of Alzheimer's disease and resided at a Skilled Nursing Facility. A review of the plan of care for the first benefit period for 04/08/2024 to 06/06/2024 included orders for the hospice aide to perform visits three times weekly. A physician's order documented on 05/29/2024 increased the aide visit frequency to five times a week. The plan of care for the second benefit period from 06/07/2024 to 08/05/2024 continued the frequency of aide visits at five times a week. The Initial Plan of Care for the first benefit period included orders for wound care for a stage four pressure wound to the patient's sacrum and for an abscess to the left breast. The sacral wound was to be aseptically cleansed with normal saline and patted dry, then packed with collagen alginate and covered with a dry dressing. Instructions were to secure the dressing with tape. The left breast wound was to be cleansed with one-quarter strength Dakin's solution, rinsed with normal saline, and pat dry. Then, the nurse was instructed to pack the wound with silver alginate, cover it with a dry dressing, and secure it with tape. On 05/09/2024, a physician's order documented a change to the wound treatment orders for the sacral wound to now pack with wound compound #4 instead of collagen alginate and secure with dry gauze and tape daily. The wound care orders were continued in the plan of care for the second benefit period from 06/07/2024 to 08/05/2024. The initial hospice aide care plan dated 04/10/2024 instructed the aide to provide a bed bath to the patient three times a week. No instructions were provided to the aide for what to do if the dressing became saturated, wet, or soiled. The aide care plan was updated on 05/29/2024 with the change in frequency of visits from three to five times a week, and the aide was instructed to provide a bed bath to the patient on Mondays and Fridays, but on Wednesdays to provide a shower with a shower chair. These instructions did not change with the update to the aide care plan on 06/07/2024 and 07/29/2024. No instructions were provided regarding what to do with the dressing during the patient's shower or if the dressing became saturated, wet, or soiled. Clinical Record 11: The patient elected the hospice benefit on 02/10/2024 with the diagnosis of unspecified heart failure and resided at home. A review of the plan of care for the second benefit period from 05/10/2024 to 08/07/2024 included orders for the hospice aide to perform visits five times a week. During a Skilled Nurse visit documented by the Registered Nurse (RN) on 06/20/2024, it was noted that the patient exhibited blisters to her bilateral lower extremities measuring 0.5 cm x 0.5 cm x 0.1 cm. A physician's order was documented on 06/20/2024 for twice-weekly wound care to the patient's bilateral lower extremities, including cleansing the area with normal saline and pat drying. Then apply Xeroform, wrap with a Kerlix dressing, and secure with tape. The hospice aide care plan dated 05/10/2024 instructed the aide to provide a shower via shower chair on Mondays, Wednesdays, and Fridays. No instructions were provided regarding what to do with the dressing during the patient's shower or if the dressing became saturated, wet, or soiled. In a Skilled Nurse Visit on 07/09/2024, the RN documented a stage one pressure ulcer wound to the patient's sacrum measuring 0.5 cm x 0.5 cm x 0.1 cm. A physician's order for wound care was also documented on 07/09/2024, which included instructions to clean the area with normal saline, apply calcium alginate, and secure it with an adhesive dressing. No frequency of dressing changes was included in the order. The nurse documented on 07/23/2024 that both wounds were healed. The aide care plan was not updated until 08/08/2024. During a joint record review and interview with the Director of Nursing on 08/16/2024 it was determined that the Registered Nurse did not provide detailed instructions to the hospice aide for each patient's wound and what to do with the wound/dressing during showers. There was also no intervention to notify the nurse if the dressing was wet, soiled, or loose.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) applicable clinical records reviewed in which a patient was discharged alive from hospice services revealed the agency did not ensure that there was documentation that the patient's discharge summary was sent to the patient's attending upon discharge. Document 1: The hospice's policy dated 10/01/2021 entitled "Patient Discharge" included in part that "... If a patient or authorized representative chooses to revoke the election of hospice care they must file a statement with the Hospice that includes the following information ... a signed statement revoking the election for Medicare coverage of hospice ... The patient's attending physician is notified by the Hospice of the patient's intent to revoke the hospice benefit. The Hospice will forward copies of the following information to the patient's attending physician: The hospice discharge summary that includes but is not limited to a summary of the patient's care (pain management, symptoms, and treatment(s); the patient's current plan of care, including the current medication profile; the latest physician orders; and Any other documentation requested ..." Clinical Record 16: The patient elected the hospice benefit on 09/15/2023 and revoked hospice services on 02/08/2024 with the diagnosis of hemiplegia following cerebral infarction with comorbid conditions that included dysphagia with a history of pneumonia and gastric tube placement. The patient resided in a skilled nursing facility. There was no discharge summary documented in the patient's clinical record. On 02/08/2024, in a Psychosocial Visit note, the Social Worker noted in part that "... LMSW conducted a visit with the patient and PCG due to PCG's request to seek speech therapy for the patient. LMSW had the PCG sign the revocation form and provided assistance with finding help in the future should she need more care, including hospice, again. LMSW notified staff of the patient revocation from hospice..." The Registered Nurse also 02/08/2024 indicated in an Unattended Discharge Note that the discharge summary was sent to the speech pathologist by checking a box; however, no discharge summary was located in the patient's medical record. During the post-discharge Interdisciplinary Group Meeting on 02/14/2024, it was noted in part that the patient was discharged on 02/08/2024 due to the patient's daughter wanting the patient to receive more restorative speech therapy. In the scanned document library and Care Coordination notes, there was no documented evidence that any of the patient's clinical information was provided to the patient's attending physician. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) and the Quality Assessment nurse on 08/14/2024, it was confirmed that the patient's medical record did not contain any documented evidence that the discharge summary or any clinical information was provided to anyone upon the patient's discharge from hospice services.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) applicable clinical records reviewed revealed the agency did not ensure that a discharge summary was documented in the patient's clinical record containing the required information. Document 1: The hospice's policy dated 01/01/2020 entitled "Patient Revocation" (PE..8) included in part that "... If a patient or authorized representative chooses to revoke the election of hospice care they must file a statement with the Hospice that includes the following information ... A signed statement revoking the election for Medicare coverage of hospice ... The patient's attending physician is notified by the Hospice of the patient's intent to revoke the hospice benefit. The Hospice will forward copies of the following information to the patient's attending physician: The hospice discharge summary that includes but is not limited to a summary of the patient's care (pain management, symptoms, and treatment(s); the patient's current plan of care, including the current medication profile; the latest physician orders; and Any other documentation requested ..." Clinical Record 16: The patient elected the hospice benefit on 09/15/2023 and revoked hospice services on 02/08/2024 with the diagnosis of hemiplegia following cerebral infarction with comorbid conditions that included dysphagia with a history of pneumonia and gastric tube placement. The patient resided in a skilled nursing facility. There was no discharge summary documented in the patient's clinical record. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) and the Quality Assessment nurse on 08/14/2024 at 1645, it was confirmed that the patient's medical record did not contain a documented discharge summary.

It is required that a hospice may contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards and has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. In 1 of 2 (50%) Durable Medical Equipment (DME) contracts reviewed revealed the agency did not ensure that the DME company was appropriately accredited. The hospice's policy "Contractual Agreements" (LD.12) dated 08/01/2020 read in part that "... As part of the Agency's annual evaluation process, the Administrator, with the assistance of other Agency personnel will monitor, evaluate, and audit the contracted services to ensure that care and services are provided according to the contract and for compliance with federal, state, accreditation (if any) ...." During the contract review on 08/15/2024 and an interview with the Administrator (Personnel Record 1), it was revealed that the supplier of Durable Medical Equipment (DME) with the contract effective date of 07/11/2018 is not a Medicare-certified supplier and is not accredited by a recognized accreditation organization. In my presence, the Administrator phoned the DME company, which is owned by the same owners as the hospice agency but is a separate company/entity and confirmed that the DME company is not accredited as required by Medicare. There was no documented evidence of a letter verifying accreditation of the DME. During the contract review on 08/15/2024 and an interview with the Administrator (Personnel Record 1), it was revealed that the supplier of Durable Medical Equipment (DME) with the contract effective date of 07/11/2018 is not a Medicare-certified supplier and is not accredited by a recognized accreditation organization. In my presence, the Administrator phoned the DME company, which is owned by the same owners as the hospice agency but is a separate company/entity and confirmed that the DME company is not accredited as required by Medicare. The hospice's policy "Contractual Agreements" (LD.12) dated 08/01/2020 read in part that "... As part of the Agency's annual evaluation process, the Administrator, with the assistance of other Agency personnel will monitor, evaluate, and audit the contracted services to ensure that care and services are provided according to the contract and for compliance with federal, state, accreditation (if any) ...."

It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by a review of clinical records, documents, interviews, and personnel records. 1 of 2 (50%) applicable clinical records reviewed of patients who requested on-call nursing visits revealed the hospice did not ensure the on-call nurse provided nursing visits as requested for the patient's change in condition. Clinical Record 1: Review of the clinical record revealed the patient elected hospice care on 5/21/22 with a terminal diagnosis of end stage renal failure. Patient was at home with daughters as caregivers and hired private duty aide sitter services. The nursing visit frequency on 5/21/22 was one time a week and 2 PRN visits for symptom management. The plan of care ordered skilled nurse for "assessment and symptom management and coordinate the plan of care". Order received 5/25/22 "Patient activity dying, family members need increased support from agency staff members for managing symptoms, increase SN frequency to daily x 5 days then re-evaluate, increase aide frequency to 5 x week". Review of the discharge summary dated 5/26/22 included the time of death at 11 am. During an interview on 10/17/22, the Director of Clinical Services stated, "The on-call nurse (Staff 4) did not report to me that she did not make a visit to the patient (Record 1) as requested by the family on 5/25/22 at 1:30 am and I was back up on-call, I would have made the visit if the on-call nurse was unable to make the visit". During interview 10/17/22, the Director of Clinical Services and Administrator stated, "Both of us are now back up to the on-call nurse and on-call nurses are instructed to call us when needed for patient visit."

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records, documents, and interviews. 1 of 2 (50%) records reviewed of patients requesting a visit by the on-call nurse, revealed the hospice did not ensure the nursing needs of the patient were met. Clinical Record 1: A review of the clinical record revealed the patient elected hospice care on 5/21/22 with a terminal diagnosis of end-stage renal failure. The patient was at home with daughters as caregivers and hired private duty aide sitter services. The ordered nursing visit frequency as of 5/21/22 was “one time a week and 2 PRN visits” for symptom management. In addition, the plan of care ordered skilled nursing for "assessment and symptom management and coordinate the plan of care". An order received 5/25/22 read in part "Patient activity dying, family members need increased support from agency staff members for managing symptoms, “increase SN frequency to daily x 5 days then re-evaluate, increase aide frequency to 5 x week". The patient's family member called the hospice on 5/25/22 at 1:30 am to report a change in the patient's condition, the patient was in distress and requested the nurse to come out to assess the patient. The discharge summary dated 5/26/22 included the patient’s time of death as 11 am. A review of the clinical record revealed missing on-call nursing note entries from the nurse (Staff 4) from the phone calls with the family on 5/25/22 and 5/26/22. During the interview on 10/17/22, the Director of Clinical Services confirmed missing on-call nursing entries in the clinical record from the on-call nurse (Staff 4). patient visit."

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, at a minimum physician order. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure physician's orders were documented in the clinical record for medications the patient was receiving. Clinical Record 1: A review of the clinical records revealed the physician's order for the Morphine on 5/21/22 did not match the physician signed-prescriptions at the contracted pharmacy on 5/21/22. The signed physician's order in the clinical record on 5/21/22 stated "Morphine oral solution 20 mg/5 ml, dose 1 ml, administer 5 mg/1 ml PO every 1-hour PRN pain/SOB”. During interview 10/17/22 on speaker phone with the contracted Pharmacist, with the Director of Clinical Services present, the Pharmacist stated, "The Pharmacy received verbal orders from the hospice on 5/21/22 for Morphine 20 mg/1ml, 0.25ml to 0.5 mg every 1-hour PRN and the prescription at the pharmacy was signed by the physician". Review of the clinical record revealed a subsequent physician's order dated 5/26/22 for "Morphine oral solution, 20 mg/5 ml, dose 1 ml, administer 0.5 mg/1 ml PO every 1-hour PRN, indication pain/SOB." During interview 10/17/22 with the Director of Clinical Services present, the contracted Pharmacist stated this order with a change in morphine concentration was not called into the pharmacy on 5/26/22. Additionally, the nursing visit note dated 5/25/22 stated in part, "Educated on continued use of Hyoscyamine and Scopolamine used for excessive secretions". Review of the clinical record revealed no physician's orders for Hyoscyamine and Scopolamine. During an interview on 10/17/22, the Director of Clinical Services confirmed there were no physician's orders in the clinical record for Hyoscyamine and Scopolamine. The RN case manager was no longer employed at the hospice agency and was not available for interview. During interview on 10/17/22, the Director of Clinical Services stated "The nurse must have selected the incorrect dosage and concentration from the drop-downs in the electronic medical record and the Pharmacy now gets the physician’s signature on the pharmacy prescription before the medication is sent out to the patient and if the incorrect concentration or dosage is called into the pharmacy, it will be corrected before it is sent out the patient". The RN who obtained the verbal order is no longer working at the hospice agency and was not able for interview.