Every finding on record at Visiting Nurse Association and Hospice of Vermont and New Hampshire, Inc.

Upon patient record review, 4 of 19 (Patients #3, 7, 10, and 13) did not contain documented evidence that the Comprehensive Assessment had included a Bereavement Risk 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 Risk Assessment is incorporated into the Plan of Care and is considered in the Bereavement Plan of Care: Patient #3: There was not documented evidence that a Bereavement Risk Assessment had been conducted within the 5-day Comprehensive Assessment process. Patient #7: SOC 03/12/25. The Spiritual Counselor was not able to connect with the patient until 03/18/25, so the RN conducted the Bereavement Risk Assessment during the admission visit. However, the content of this assessment consisted of only, "Patient is not active in religion." Patient #10: SOC 02/01/25. The Spiritual Counselor was not able to connect with the patient until 02/11/25 to conduct the Bereavement Risk Assessment. Patient #13: SOC 02/12/25. The Spiritual Counselor was not able to connect with the patient until 02/24/25, so the RN conducted the Bereavement Risk Assessment during the admission visit. However, the content of this assessment consisted of only, "Patient is Catholic."

Upon patient record review, 1 of 19 (Patient #4) did not contain evidence that a Registered Nurse had been designated to ensure continuous assessment of the patient and family's needs, and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #4: The 02/18/25 RN SOC visit reflected that the patient had a recent fall, resulting in a bruise on the right side of the head, and a scab on the right hand. The visit note for the next nursing visit on 02/20/25 did not evidence that the nurse had followed up on the status of these areas of concern.

Upon patient record review, 1 of 19 (Patient #2) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #2: During Surveyor-attended home visit on 03/18/25, it was noted that the patient had a golf-ball-sized bulge emerging from the patient's left eye inner canthus. The patient reported that he had recently been diagnosed with rare frontal brain cancer, and that his doctors had told him that the cancer had 'pushed out' of this eye area. There was nothing included on the most recent 03/11/25 IDG POC regarding any nursing interventions related to this area of concern, such as but not limited to the nurses assessment of, measurement of/monitoring of growth in size, care of (such as moistening of if indicated), nor monitoring for infection of (the patient repeatedly wiped over this bulge during the Surveyor home visit). The patient reported fluid drainage from this area.

Upon patient record review, 1 of 19 (Patient #2) did not contain evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #2: The IDG POC assigned a Chaplain visit frequency of (1) visit every week, effective between 02/11/25 and 04/22/25. There was no visit made the week of 02/23-03/01/25.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that an initial Aide Skills Competency Assessment had been performed on the Aide, as per CMS guidelines: Personnel #8: An Aide Skills Competency Assessment was conducted between 10/29/24-11/05/24. However, the following tasks were not evaluated for: • Basic elements of body functioning, and changes in body function, that must be reported to an Aide's supervisor • Maintenance of a clean, safe, and healthy environment • Recognizing patient emergencies and knowledge of emergency procedures and their application • The physical, emotional, and developmental needs of and ways to work with the populations served by the Hospice, Additionally, there was not documented evidence of the Aide having been observed providing the following tasks on a patient/pseudo-patient/responsive manikin: · Bed bath · Sponge and tub bath

Upon patient record review, 7 of 19 (Patients #1, 4, 8, 9, 10, 11, and 13) did not contain evidence that the Hospice Aide assignments and duties were: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The Aide POC effective 03/10/2025 assigned: "Assistance with shower or sponge bath", enabling the Aide and/or patient to make such choice. There was no notation made indicating that, 'The patient/caregiver is cognitively and functionally able to make this bath choice.' Patient #4: The Aide POC effective 02/18/2025 assigned: 1) Shampoo as needed; and 2) File fingernail and toenails as needed. Patient #8: The Aide POC effective 03/11/2025 assigned: 1) Assist Shampoo prn; 2) Assist bed bath prn; 3) Assist Shower prn; and 4) File fingernail and toenails prn. Patient #9: The Aide POC effective 12/17/2024 assigned: 1) Assist Shampoo prn; 2) Assist bed bath prn; 3) Assist Shower prn; and 4) File fingernail and toenails prn. Patient #10: The Aide POC effective 02/01/2025 assigned: 1) Assist Shampoo prn; and 2) Assist bed bath prn. Patient #11: The Aide POC effective 02/25/2025 assigned: 1) Assist Shampoo prn; 2) Assist Shower prn; and 3) File fingernail and toenails prn. Patient #13: The Aide POC effective 01/12/2025 assigned: 1) Assist Shampoo prn; 2) Assist bed bath prn; 3) Assist Shower prn; and 4) File fingernail and toenails prn.

Upon patient record review 4 of 19 (Patients #1, 4, 10, and 12) did not contain documented evidence that the Hospice Aide had provided care/services that were: • Ordered by the Interdisciplinary Group • Included in the Aide Plan of Care Patient #1: The Aide POC effective 03/10/2025 assigned: 1) Assist with shower or sponge bath; 2) Fingernail/Toenail filing; and 3) Change bed linens. None of these interventions were provided/documented on the Aide visits of 03/10, 03/12, or 03/14/2025. Patient #4: The Aide POC assigned: 1) Assist with dressing QV, which was not done/documented for the Aide home visits made February 24, 25, 26, 2025 nor on March 1, 2, 3, 4, 6, 2025; 2) Assist with foot care QV, which was not done/documented for the Aide home visits made February 24, 25, 26, 2025 nor on March 1, 2, 3, 4, 6, 2025; 3) Oral care QV, which was not done/documented for the Aide home visits made February 25, 26, 2025 nor on March 1, 2, 3, 4, 2025; 4) Shampoo QV, which was not done/documented for the Aide home visits made February 24, 25, 26, 2025; and 5) Hair care QV, which was not done/documented for the Aide home visits made February 25, 26, 2025 nor on March 1, 3, 4, 2025. Patient #10: The Aide POC dated 02/01/25 assigned the Aide at a visit frequency of 2x per week. There was only one Aide visit made the week of 02/02-02/08/25. Patient #12: The 01/17/25 Aide POC assigned: 1) Assist with ambulate QV, which was not done/documented for the Aide home visits of January 22, 24, 31, 2025, February 3, 5, 2025, nor March 6, 10, 2025; 2) Change linens QV, which was not done/documented for the Aide home visits made March 6, 10, 13, 2025, and 3) Shampoo QV, which was not done/documented for the Aide home visits made January 22, 24, 31, 2025, February 3, 5, 2025 nor on March 6, 10 2025;

Upon patient record review, 1 of 19 (Patient #9) did not contain evidence that all entries were complete: Patient #9: The 12/17/24 RN SOC visit noted that the patient had an actively accessed Medi-port. A verbal order was obtained on 12/19/25 for an Hospice RN to de-access the port per Hospice policy. An RN visit dated 12/21/24 documented, "Port de-accessed per Hospice procedure," without the details of such intervention.

Upon patient record review, 2 of 19 (Patients#1 and 4) did not contain evidence that the Hospice had provided the following required information to the SNF: Patient #1: Election of Hospice Benefit form Patient #4: Election of Hospice Benefit form; and The Physician initial Certification of the Terminal Illness