Every finding on record at Visiting Nurse Association Health Group of New Jersey, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals 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. Agency policy #14.13 "Plan of Care" (reviewed 10/2023) read in part, "Changes in the plan of care will be noted within the following: Problem list with goals." In 2 of 27 (7%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals based on problems identified in the comprehensive assessments. Clinical Record 7: The patient elected hospice care on 07/18/2024 with a diagnosis of peripheral vascular disease. The skilled nursing (SN) admission visit note dated 07/18/2024 documented, "Patient requires a urinary catheter, type of catheter: indwelling." The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Reports dated 07/31/2024 and 08/14/2024 did not document patient and family goals for the identified indwelling catheter. On 12/13/2024, the physician ordered, "Levofloxacin 250 mg 1 tablet by mouth 2 times daily for 7 days Reason: UTI." The skilled nursing (SN) visit note dated 12/13/2024 documented, "Patient noted with foul-smelling urine. Call to Dr. (name) verbal order (VO) Levaquin 250mg once a day for 7 days." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 12/18/2024 and 01/02/2025 did not document patient and family goals for the identified urinary tract infection (UTI). Clinical Record 27: The patient elected hospice care on 06/30/2024 with a diagnosis of malignant neoplasm of the esophagus. On 10/08/2024, the physician ordered, "Cipro 500 mg 1 tablet by mouth 2 times daily for 7 days Reason: UTI." The SN visit note dated 10/08/2024 documented, "Pt has suspected UTI and antibiotics (ABX) delivered." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 10/15/2024 and 10/29/2024 did not document patient and family goals for the identified urinary tract infection. During an interview on 03/13/2025, the Vice President of Hospice/ Alternate Administrator confirmed that the plan of care for clinical record 7 did not include goals related to the urinary tract infection and indwelling catheter, and the plan of care for clinical record 27 did not include goals for the urinary tract infection.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Agency policy #H1.02 "Hospice Scope of Services and Standards of Practice" (reviewed 09/2023) read in part, "Volunteers must be used in day-to-day administrative and/or direct patient care roles to assist patients/families of the (name of agency) Hospice Program through: Direct patient care hours, Administrative hours." The Volunteer Activity report dated 01/01/2024 through 01/01/2025 was reviewed with the Volunteer Coordinator [Personnel Record 9] on 03/11/2025. The Volunteer Coordinator confirmed that the percentage of volunteers that provided day-to-day administrative and/or direct patient care services was 3.66% for 01/01/2024 through 01/01/2025, less than the required 5%. During an interview on 03/11/2025, the Chief Nursing Officer/Administrator confirmed that volunteer utilization was below the requirement of 5% and stated in part, "COVID impacted our volunteer program, working hard to rebuild it." The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that a hospice aide provides services ordered by the interdisciplinary group and included in the plan of care. This standard was not met as evidenced by review of clinical records, policy review and interview. The agency's policy #10.5 "Communication of the Home Health Aide Care Plan" reads in part, "The Home Health Aide works under the direction of the licensed Registered Nurse (RN) or Therapist. The Plan of Care (POC) is developed by the RN based on the patient's care needs. RN communicates with the Home Health Aide to discuss the patient's needs." 1 of 13 (8%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the aide provided services ordered by the interdisciplinary group and included in the plan of care. Record #90936: For the benefit period dated 4/5/2022-4/28/2022, the "Aide Care Plan Report" dated 4/5/2022 assigned "Personal Care: Shampoo, Weekly Wed." The hospice aide documented the service "shampoo" as completed during the aide visits dated 4/14/2022, 4/15/2022, 4/18/2022, 4/19/2022, 4/20/2022, 4/21/2022, 4/22/2022, and 4/25/2022, or twice weekly. The finding was validated by the Director of Hospice Education and Performance Improvement during an interview and a joint review of the record on 5/5/2022 at 1:00 pm.