Every finding on record at Virginia Health Hospice, LLC

Upon patient record review, 3 of 19 (Patients #10,11,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #10: POC indicated patient on Oxygen 3L/min via NC. Oxygen was not included on medication profile. Corrected on Site. Patient #11: Patient has Polyethylene Glycol listed on medication profile with no diluent (3/13/24) Corrected on Site. Patient #13: Patient has Polyethylene Glycol listed on medication profile with no diluent (3/14/24) Corrected on Site.

Upon patient record review, 19 of 19 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19: Did not have evidence in the patient record that the comprehensive assessment includes an initial bereavement assessment completed within the 5 days. Baseline assessment completed late (during survey) on 3/21/24.

Upon patient record review, 2 of 19 (Patients #11,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #11: Patient has Polyethylene Glycol listed on POC with no diluent (3/13/24) Corrected on Site. Patient #13: Patient has Polyethylene Glycol listed on POC with no diluent (3/14/24) Corrected on Site.

Upon patient record review, 3 of 19 (Patient #1,2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had an alternating pressure mattress and fall mat. These were not included on the Plan of Care. Patient #2: This patient had a wheel chair with gel pad, fall mats x 2 and bed slide. These were not included on the Plan of Care. Patient #3: This patient had a walker and cane. These were not included on the Plan of Care. Additionally, DME list on plan of care included an overlay mattress and commode. These items were not present in patient room at the SNF.

Upon patient record review 8 of 19 (Patients #3,4,5,6,7,10,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care (POC) Patient #3: The POC listed Aide visit frequency of, 2 X's per week (2/27/24). For the 1st Benefit Week there were no visits made by the Aide. Patient #4: The POC listed Aide visit frequency of, 2-3 X's per week (12/3/23). This frequency interval is not specific for Aide services. Patient #5: The POC listed Aide visit frequency of, 2-4 X's per week (2/12/24). This frequency interval is not specific for Aide services. Patient #6: The POC listed Aide visit frequency of, 2 X's per week (2/27/24). For the 1st Benefit Week there were no visits made by the Aide. Patient #7: The POC listed Aide visit frequency of, 2-4 X's per week (1/20/24). This frequency interval is not specific for Aide services. Patient #10: The POC listed Aide visit frequency of, 2 X's per week (2/23/24). For the 1st Benefit Week there were no visits made by the Aide. Patient #13: The POC listed Aide visit frequency of, 2 X's per week (3/14/24). For the 1st Benefit Week there were no visits made by the Aide. Patient #14: The POC listed Aide visit frequency of, 2 X's per week (10/2/23). For the 1st Benefit Week there was one visit made by the Aide on 10/3/23 only.

Upon patient client record review, 6 of 19 (Patients #1,2,5,8,11,19) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patients #1,2,5,8,11,19: Beneficiary’s attending physician selected is a nurse practitioner (NP). The NP signed the certification of terminal illness (CTI) as the attending physician. The NP did not meet CTI requirement to sign as a physician.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #15: The transfer summary did not include all the elements as required, these were: Ÿ ŸŸ • patient's physician • transfer orders • advanced directives • plan of care Ÿ • consents • certification of terminal illness

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #2: Did not have Criminal Background Check in employee file. Agency submitted documentation during survey to have this updated.