Every finding on record at Visiting Nurses Hospice Inc

Upon patient record review 2 of 11 (Patient #1, 11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: No evidence to support a comprehensive spiritual or psychosocial assessment was completed. Patient #11: No evidence to support a comprehensive psychosocial assessment was completed.

Upon patient record review, 1 of 11 (Patient #1) 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. Patient #1: No evidence to support an initial comprehensive bereavement assessment was completed.

Upon patient record review, 1 of 5 applicable (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #7: Aide frequency was changed from 2 times a week to 1 time a week on 9/1/2022, visit frequency made appropriately. However, no evidence to support the aide care plan was updated to reflect the new frequency.

Upon patient record review 1 of 5 applicable (Patient #11) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #11: Initial plan of care ordered Aide 2xweek. Only one visit was made the week of 5/26/2022.

Upon patient record review, 1 of 4 applicable (Patient #8) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #8: The CTI for period #9, 4/5/2022 - 6/3/2022, did not contain the F2F Certification statement/summary by the physician. It is noted that the CTI contained the date the F2F was performed.

Upon patient client record review, 1 of 11 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: MSW documented in their initial assessment that the patient resided in a SNF and was cared for by SNF staff. This information was inaccurate. The patient resides at home with spouse and cared for by family.