Every finding on record at Vineta Hospice Care, Inc

Based on interview and record review, the agency failed to provide evidence of ongoing Performance Improvement Projects (PIPs is a concentrated effort on a particular problem in one area of the agency or agency-wide) based on the agency's quality assessment and performance improvement (QAPI) data collected and failed to establish measurable goals to evaluate the effectiveness of quality interventions from January 1, 2025, to January 29, 2026. These failures had the potential to cause problems in health outcomes, patient safety, and quality of care to go unaddressed and continue for a universe of 22 patients. --- Findings: A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder for period of January 1, 2025, to January 29, 2026, was conducted. There was no documented evidence to show ongoing PIPs from the actual issue that emerged after quality indicator was identified from the data collection and analysis reviewed. During an interview on January 29, 2026, at 3:00 PM, with the QAPI nurse and Director Patient Care Services/Administrator (DPCS/Admin), the QAPI nurse stated she is the person responsible for the QAPI program. The QAPI nurse further stated that the agency did not have ongoing PIPs at this time for the actual issue from the quality indicator identified, and it should have been initiated. The DPCS/Admin stated that she was unfamiliar with how the PIP are selected and implemented to address specific issues or areas for improvement.  During a concurrent interview and record review, on January 29, 2026, at 3:10 PM, with the QAPI nurse and DPCS/Admin, both QAPI nurse and DPCS/Admin reviewed the agency’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, revised May 2024, the P&P indicated, “Mission. All QAPI activities must support and be aligned with the mission of the organization. Purpose. The purpose of The Hospice QAPI Plan is to provide a strategy for the systematic organization wide implementation of quality assessment and performance improvement activities. This will ensure that the organization provides appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives. To show measurable improvement in indicators that demonstrate an improvement in palliative outcomes and end-of-life support systems .To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, hospice services and operations. To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement. To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained … Responsibility of QAPI coordinator…. Is responsible for coordinating and facilitating all quality improvement activities… assisting in implementation of corrective action as appropriate… ”. The QAPI nurse stated that she should have regularly implemented and maintained ongoing PIPs focused on maintaining or improving patient safety and care quality. The DPCS/Admin stated that the agency did not follow its own policy.

Based on observation, interview, and record review, the agency failed to ensure nursing services were provided in accordance with accepted standards of practice related to medication management and maintenance of home clinical records for two of four sampled patients (Patient 1 and 3) when: 1. For Patient 1, the home clinical record did not include the Plan of Care and a current medication profile (MP), and the MP did not reflect the medications available in the home. 2. For Patient 3, one medication was observed to be past their expiration dates but remained available for use. These failures had the potential to result in inaccurate medication reconciliation, insufficient nursing oversight and unsafe medication management, which could place Patient 1 and 3 at risk for medication errors and compromised patient safety and well-being. --- Findings: 1. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of July 25, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice [medical care for people who are expected to live six months or less] services) of January 21, 2026, to March 21, 2026.  Patient 1 had primary diagnoses that included unspecified systolic heart failure (the heart muscle becomes weak and often enlarged, leading to a reduced pumping capability) and hyperlipidemia (an excess of lipids or fats in your blood). During a home visit on January 27, 2026, at 11:15 AM, with the Director of Patient Care Services/Administrator (DPCS/Admin), in the presence of Patient 1 and Patient 1’s daughter, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both  DPCS/Admin and Patient 1’s daughter confirmed that these essential documents were not available. During a concurrent observation and interview in a home visit on January 27, 2026, at 11:20 AM, with the DPCS/Admin, Patient 1’s actual medication bottles available at home were compared with Patient 1’s most current MP. The  DPCS/Admin examined a bottle of Rosuvastatin calcium (a prescription medication used to lower "bad" cholesterol and triglycerides (types of lipids) in the blood). This bottle contained 20 mg (milligram-a unit of measure) tablets. However, Patient 1’s MP indicated “Rosuvastatin calcium 40 mg, 1 tablet once daily at bedtime,". The DPCS/Admin acknowledged and confirmed that there was a discrepancy in the strength of the medication required for Patient 1.   During an interview on January 27, 2026, at 11:25 AM, with Patient 1’s daughter, Patient 1’s daughter stated, “She [Patient 1] had been taking Rosuvastatin calcium 20 mg before even starting with hospice. Her doctor is aware of it.” During a concurrent observation and interview in a home visit on January 27, 2026, at 11:30 AM, with the DPCS/Admin. The DPCS/Admin examined a bottle of Spironolactone (a prescription medication used to treat high blood pressure and heart failure). This bottle contained 25 mg tablet, take ½ (half) tablet (12,5 mg) once daily. However, Patient 1’s MP indicated “Spironolactone 25 mg, 1 tablet once daily,". The DPCS/Admin acknowledged and confirmed that there was a discrepancy in the dosage instructions for the medication that Patient 1 needs to consume. During an interview on January 27, 2026, at 11:35 AM, with Patient 1’s daughter, Patient 1’s daughter stated, “She [Patient 1] had been taking Spironolactone 25 mg half tablet before even starting with hospice. Her doctor is aware of it.” 2. A review of Patient 3’s face sheet indicated a start of care date of August 19, 2025, with a certification period of November 17, 2025, to August 14, 2026.  Patient 3 had primary diagnoses that included Alzheimer`s disease (a decline in mental function including memory, language, problem-solving, and cognition, severe enough to interfere with daily life) and polyosteoarthritis (a condition where pain and swelling occur in multiple joints at once). During a concurrent observation and interview in a home visit on January 28, 2026, at 3:30 PM, with License Vocational Nurse 1 (LVN 1) and in the presence of Patient 3’s daughter an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current Medication  Profile (MP).  LVN 1 checked a bottle of Tramadol (a prescribed for moderate to severe pain, including chronic conditions that require around-the-clock treatment) indicated “EXP 12/2024” [Expired December 2024 (medication had been expired for 1 year and 27 days)]. Patient 3’s MP indicated “Tramadol hydrochloride 50 mg, ½ [half] tab [tablet], daily as needed for pain.” Patient 3’s daughter stated, "I didn't [did not] notice that the medication was expired because my mom doesn't [does not] take it very often." During an interview on January 29, 2026, at 9:30 AM, with the DPCS/Admin. The DPCS/Admin stated that the visiting nurse and case manager are responsible for reviewing and updating the MP during their visits. The printed MP should have been updated accordingly. Furthermore, the DPCS/Admin stated, "The visiting nurse or case manager should have included the process of checking all home medications for correct orders, expiration dates, and reordering medication as needed. I do not know why it was not done." During a concurrent interview and record review on January 29, 2026, at 9:40 AM, the DPCS/Admin reviewed the agency’s policy and procedure (P&P) titled “Job description. Job Title/Position: Registered Nurse,” undated, which indicated, “Communication. 1. Completes, maintains and submits accurate and relevant clinical notes regarding patient's condition and care given… 2. Communicates with the physician regarding the patient's needs and reports changes in the patient's condition; obtains/receives physicians' orders as required. 3. Communicates with community health related persons to coordinate the care plan. 4. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician …”. The DPCS/Admin stated the agency did not follow the policy.  During a concurrent interview and record review on January 29, 2026, at 9:50 AM, the DPCS/Admin reviewed the agency’s P&P titled “Medication Profile,” undated, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient's current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. …”. The DPCS/Admin stated the agency did not follow the policy.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#3 it was noted lack of spiritual counselor (SC) interventions on the POC however the frequency of visits for the is documented on the POC as 1 per Cert Period + 1 PRN Visits - Reason For PRN: per month for spiritual / emotional care and support. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#2 it was noted an order for Midodrine 10 mg four times per day as needed for hypotension. The order lacked the BP parameters for administration and precautions. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients who were discharged alive. During LiveD/C RR#2 it was noted the patient was discharged for an extended prognosis and signed a Notice of Non Medicare Coverage (NOMNC) form the same date as the discharge. The requirement for the date signed by the patient must be at least 2 days prior to the discharge date. This was discussed with the organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV2 it was noted a bottle of Metformin 850 mg and a bottle of Metformin 500 mg was present in the home. The SN discussed with the daughter who is not a regular caregiver was in the home, that the Metformin 850mg had been discontinued 2 week prior and needed to be discarded. The SN did not check the medi-planner boxes to assess if the correct dose was in each day's box. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR3 it was noted the initial bereavement assessment and MSW initial assessment were not entered into the computer within the organization time frame for submission of documents per policy. This was discussed with the organization leadership.

Observed in Record Review. In 10 of 10 patient records reviewed, During RR1 it was noted some of the goals were not measurable: Be able to cope with changes at this time, prevent discomfort due to increasing edema, facilitate bowel elimination and comfort, Patient will be kept clean and dry ,be able to cope with changes at this time. During review of the POC for RR2 it was noted some of the goals were not individualized and lacked time frames to assess if goals were achieved as follows: Achieve and maintain blood pressure readings at pt baseline, pcg will verbalize/express understanding of medication /treatment orders and side effects, family/PCG will verbalize understanding of oxygen safety intervention, facilitate bowel elimination and comfort, O2 treatment as needed to achieve and maintain Pt comfort and facilitate a spiritual environment to begin the bereavement process at this time. During RR3 it was noted some of the goals lacked the time frame to assess if achieved and were not individualized as follows: pcg will verbalize/express understanding of medication /treatment orders and side effects, facilitate bowel movement, minimize complications due to impaired mobility and pt needs will be met on a day to day basis as communicated. RR4 goals as follows lacked time frames to assess if goals achieved: Be able to cope with changes at this time, Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, prevent discomfort due to increasing edema, prevent potential skin problems for comfort, Minimize complications due impaired mobility, and pain will remain in comfortable level during care. RR5 POC goals lacked specificity as follows: Minimize complications due impaired mobility, Pt will have adequate food and fluids as tolerated or desired, and pain will remain in comfortable level during care. RR6 POC goals lacked specificity as follows: Prevent discomfort due to increasing edema, Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, pain will remain in comfortable level during care, minimize complications due impaired mobility, relieve constipation and associated discomfort (e.g., bloating, abdominal pain), promote regular, comfortable bowel movements as tolerated. RR7 POC goals were not individualized as follows: Achieve and maintain blood pressure readings at pt baseline, minimize complications due impaired mobility, pt needs will be met on a day to day basis as communicated, pain will remain in comfortable level during care. RRHV1 goals lack time frames to be able to assess if goals were accomplished: Prevent discomfort due to increasing edema, facilitate bowel elimination and comfort, patient will be kept clean and dry. RRHV3 goals lacked specificity as follows: patient will restore normal level of thyroid hormone, maintain optimal mobility and independence, increase strength /energy for optimal functional activities, minimize complications, Pt needs will be met on a day to day basis as communicated, Pt will have optimal level of sleep. RRHV2 POC lacked goals that were measurable as follows: Achieve and maintain blood pressure reading within normal limits, pcg will verbalize/express understanding of medication /treatment orders and side effects., prevent potential skin problems for comfort, minimize complications due impaired mobility, pt needs will be met on a day to day basis as communicated, pain will remain in comfortable level during care, SC will be available whenever needed. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 10 patient records reviewed, During RR1, RR3, RR5 and RR6 it was noted the patients were prescribed Eliquis 5mg twice daily. The POC lacked interventions for instruction on s/s bleeding and bleeding precautions. During RR4 it was noted orders to cleanse (legs and feet) with normal saline, pat dry, Apply Clotrimazole 1% ointment/cream to affected areas and leave open to air twice daily as needed related to inflammation of the LEs. The order lacked the PRN reason for the wound care and who was to provide the treatment. In addition interventions related to the integument system related to the inflammation was not added to the POC. During RR6 and RRHV2 it was noted a frequency of visits for the MSW of 1x/certification however the POC lacked MSW interventions. This was discussed with the organization leadership.

Observed in Record Review. In 10 of 10 patient records reviewed, During RR1- RR7, and RRHV1-RRHV3 it was noted lack of the number of PRN visits approved by the IDG for the MSW, SC and SN. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 10 patient records reviewed, During RR5 it was noted during the initial MSW assessment the Patient declined services and referrals at this time and agreed to notify hospice staff of any future needs The POC was not updated at the next IDG meeting 9 days later to include a change in the MSW frequency. During RR7 the MSW assessment documented the patient/PCG refused further visits after initial assessment completed. The POC was not updated to include a change in the MSW frequency. This was discussed with the organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV2 it was noted the SN did not assess the patient's back per the POC order to document the patient's skin status every visit. This was discussed with the organization leadership.

Observed in Individual Tracer. In 2 of 3 home visits conducted, During RRHV2 it was noted the SN did not don gloves before removing the diabetic patient's socks to assess the patient's feet. In addition the SN after using the blood glucose monitor did not perfrom hand hygiene after removing his gloves. During RRHV3 it was noted the SN did not perform hand hygiene at the beginning of the visit prior to providing care. It was also noted the SN after taking vital signs took each piece of equipment disinfected with a Clorox wipe and placed equipment back in the bag immediately. The SN did not don gloves to assess the patient's back and upper buttock area below the patient's incontinent brief. This was discussed with the organization leadership.

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR4 review it was noted the initial competency evaluation for the hospice aide was not documented as completed by observing the aide's performance with a patient or pseudo patient. This included: Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. The method of evaluation was documented as V, verbal. This was discussed with the organization leadership.

Observed in Leadership Session. The organization did not follow policies and procedures that guide and support patient care, treatment, or services as evidence by condition level findings in 418.100 and 418.56. This was discussed with the organization leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV2 and RRHV3 it was noted the prescriptions delivered were not in accordance with the patient's plan of care. During RRHV3 a prescription for Nystatin powder was delivered by the contracted pharmacy the end of September 2025 however the medication was discontinued in June 2025. During RRHV2 it was noted in the patient home, a bottle of both Metformin 500 mg and a bottle of Metformin 850mg was delivered by the pharmacy days prior to the home visit. The Metformin 850mg was discontinued the beginning of September 2025. The organization did not have a process in place to identify when contracted pharmacy was not meeting contract agreement related to dispensing accuracy. This was discussed with the organization leadership.

Observed in HR File Review. In 8 of 8 HR files reviewed, During HR1, HR2, HR3, HR4, HR5, HR6, HR7 and HR8 it was noted the orientation was not hospice specific. The form used was an orientation to Home Health, Care and Services provided by home health. The files included all hospice staff including the medical directors. In addition HR8 lacked an orientation to the specific duties of the DPCS and Administrator designee. This was discussed with the organization leadership.

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR5 it was noted lack of an initial competency for the medical director designee. This was discussed with the organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, During HVRR3 it was noted gabapentin was included on the medication profile. The patient caregiver stated the patient has not been prescribed gabapentin. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During LiveD/C RR1 it was noted the organization, although a medication profile was sent to the receiving facility, a d/c summary was not documented as sent to the receiving hospital. This was discussed with the organization leadership.

Observed in Document Review. In 1 of 4 contracts reviewed, During review of the SNF contract it was noted lack of a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was discussed with the organization leadership.

Observed in Document Review. In 1 of 4 contracts reviewed, During review of the therapy contract it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the organization leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, agency staff failed to follow manufacturer's guidelines for cleaning equipment. In HV#1 and HV#2 the nurse cleaned her stethoscope and blood pressure cuff with a disinfectant wipe and immediately returned the equipment to her bag without allowing for drying time as per manufacturer's instructions. This was validated with the nurse observed.