Every finding on record at VNA at Hcs

Based on interview and request for review of the Emergency Preparedness Program (E.P.P.), it was determined the facility failed to ensure the E.P.P. was centrally located and available to facilitate the review in a timely manner. --- Review of the Emergency Preparedness Program on 12/30/24 between 9:00 a.m. and 11:35 with Staff F (Administrator), Staff G (Center Executive Officer), and Staff H (Administration Assistant) revealed the facility was unaware of the location of the current E.P.P. binder. A request was made for the documents at 9:10 a.m., 9:25 a.m., 9:45 a.m. 10:06 a.m., and was finally received at 10:13 a.m. The E.P.P. documents/binder needed to be re-printed from the previous version (still within the required update timeline) and placed in a folder to facilitate review. Multiple Staff members that had received a request for the documents were unable to locate any documentation or identify where the documentation was supposed to be available until Staff F arrived at the facility to assist with the survey review. Interview on 12/30/24 with Staff F and Staff G revealed the designated E.P.P. coordinator was unavailable for contact or questions during the E.P.P. survey review.

Based on interview and record review, it was determined that the hospice agency failed to ensure that visit frequencies were provided in accordance with the plan of care for 4 of 16 charts reviewed in a final sample of 19 patients (Patient Identifiers are #1, #7, #11 and #12). Findings include: --- Patient #11 Review on 12/31/24 of Patient #11's "Hospice Plan of Care" for certification period of 12/9/24 to 3/8/25 revealed a physician's order for a Hospice Aide 1 time a day for 90 days (meaning 7 days a week) beginning on 12/9/24. Further review revealed there was not a standing physician's order for approval for missed visits for the hospice aide. Review on 12/31/24 of Patient #11's Visit Calendar revealed there were 6 aide visits the week of 12/8/24 to 12/14/24 (missed visit on 12/11/24); 6 aide visits the week of 12/15/24 to 12/21/24 (missed visit on 12/19/24); and 5 aide visits the week of 12/22/24 to 12/28/25 (missed visits on 12/25/24 and 12/27/24). Review on 12/31/24 of Patient #11's medical record revealed there was no documentation that the provider had been notified of the missed visits. Interview on 12/31/24 at 2:30 p.m. with Staff F (Administrator) confirmed the above missed visits. Interview on 1/3/25 with Staff D confirmed the above. Patient #12 Review on 12/31/24 of Patient #12's "Hospice Plan of Care" for certification period of 11/15/24 to 2/12/25 revealed an order for a Hospice Aide 3-4 times a week beginning the week of 11/17/24. Further review revealed under interventions "Aide: Missed visits approved for patient driven circumstances, i.e., patient scheduling conflicts, patient refusal, and weather conditions that jeopardize clinician's or patients' safety". Review on 12/31/24 of Patient #12's visit calendar for the hospice aide for the week of 12/22/24 to 12/28/24 revealed there were 2 aide visits made that week (instead of at least 3). Further review revealed on 12/25/24 the missed visit was described as "holiday" and on 12/26/24 the missed visit was described as "staff illness". Review on 12/31/24 of Patient #12's medical record revealed no communication to Patient #12's physician regarding the missed visits. Interview on 12/31/24 at 2:30 p.m. with Staff E (Clinical Office Coordinator) confirmed the above. Patient #1 Review on 12/30/24 of Patient #1's "Hospice Plan of Care" for certification period of 11/3/24 to 1/31/25 revealed an order for a Hospice Aide 2 times a week beginning the week of 11/3/24. Further review revealed under interventions "Aide: Missed visits approved for patient driven circumstances, i.e., patient scheduling conflicts, patient refusal, and weather conditions that jeopardize clinician's or patients' safety". Review on 12/30/24 of Patient #1's visit calendar for the hospice aide for the week of 11/3/24 to 11/9/24 revealed there was 1 visit made that week. Further review revealed the week of 11/10/24 to 11/16/242 there were no aide visits (missed visits on 11/12/24 and 11/15/24); The week of 11/17/24 to 11/23/241 1 aide visit was made (missed visit on 11/22/24); The week of 11/24/24 to 11/30/24 no aide visits made (missed visits on 11/26/24 and 11/29/24); The week of 12/1/24 to 12/7/24 1 visit made (missed visit on 12/6/24); The week of 12/8/24 to 12/14/24 1 visit made (missed visit on 12/13/24); The week of 12/15/24 to 12/21/24 1 aide visit made (missed visit on 12/20/24); and the week of 12/22/24 to 12/28/24 no aide visits made (missed visits on 12/24/24 and 12/27/24). Interview on 12/30/24 with Staff D (Director of Clinical Operations) confirmed that the visits were missed, and that there was no documentation for the reason the visits were missed. Review on 12/31/24 of Patient #1's medical record revealed no communication to Patient #1's physician regarding the missed visits. Patient #7 Review on 12/31/24 of Patient #7's "Hospice Plan of Care" for certification period of 10/7/24 to 1/24/25 revealed an order for a Hospice Aide 2 times a week beginning the week of 10/27/24. Further review revealed under interventions "Aide: Missed visits approved for patient driven circumstances, i.e., patient scheduling conflicts, patient refusal, and weather conditions that jeopardize clinician's or patients' safety". Review on 12/31/24 of Patient #7's visit calendar for the hospice aide for the week of 10/27/24 to 11/2/24 revealed there was 1 visit made that week. Further review revealed for the week of 11/10/24 to 11/16/24 1 aide visit was made (missed visit on 11/16/24); and for the week of 11/24/24 to 11/30/24 1 aide visit was made (missed visit on 11/29/24). Interview on 1/2/25 with Staff D confirmed that the visits were missed, and that there was no documentation for the reason the visits were missed. Review on 12/31/24 of Patient #7's medical record revealed no communication to Patient #7's physician regarding the missed visits.

Based on interview and record review, it was determined that the facility failed to have a registered nurse (RN) assess the quality of care and services provided by the hospice aide and to ensure that services ordered met the patient/family needs no less frequently than every 14 days for 4 of 13 patients reviewed for supervisory visits in a final sample of 19 patients. (Patient identifiers are #9, #11, #13 and #15.) Findings include: --- Patient #11 Review on 12/31/24 of Patient #11's "Hospice Plan of Care" for certification period of 9/10/24 to 12/8/24 revealed Patient #11's Start of Care was on 9/10/24. Further review revealed a physician's order for a Hospice Aide 2 times a week for 1 week, then 4-5 times a week for 12 weeks beginning the week of 9/11/24. Review on 12/31/24 of Patient #11's "Hospice Plan of Care" for certification period of 12/9/24 to 3/8/25 revealed a physician's order for a Hospice Aide 1 time a day for 90 days (daily) beginning on 12/9/24. Review on 12/31/24 of Patient #11's medical record, including calendar visits and RN notes, revealed that there had been no supervisory visits performed for the Hospice Aide visits from 9/11/24 through 12/31/24. Interview on 12/31/24 at 2:45 p.m. with Staff D confirmed that there had been no supervisory visits performed for Patient #11. Patient #13 Review on 12/31/24 of Patient #13's "Hospice Plan of Care" for certification period of 11/29/24 to 1/27/24 revealed the following orders: Hospice Aide 1 visit per week for 1 week (start on 11/29/24 and end on 11/30/24) and (Hospice) Aide 3 to 4 visits per week for 8 weeks beginning on 12/1/24. Review on 12/31/24 of Patient #13's visit calendar and RN progress notes revealed there had been a Hospice Aide supervisory visit on 12/2/24. Further review revealed there had been no additional supervisory visits conducted by an RN through the day of the audit 12/30/24 (28 days). Interview on 12/31/24 at 1:20 p.m. with Staff D confirmed the above. Patient #15 Review on 12/30/24 of Patient #15's "Hospice Plan of Care" for certification period of 9/20/24 to 11/18/24 revealed physician's orders for a Hospice Aide 1 time a week for 1 week; then 3 times a week for 8 weeks; then 1 time a week for 1 week beginning during the week of 9/20/24. Review on 12/30/24 of Patient #15's medical record, including the visit calendar and RN progress notes revealed there had been a (Hospice) Aide supervisory visit on 10/31/24. Further review revealed there was no additional supervisory visits conducted until 11/18/24 (18 days). Interview on 12/31/24 at 1:20 p.m. with Staff D confirmed the above. Review on 12/31/24 of the facility's undated policy titled "Home Health/Hospice Aide Supervisory Visits" revealed, "...The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days if the patient is receiving skilled services...Supervisory visits and overall supervision will be documented in the clinical record..." Patient #9 Review on 12/31/24 of Patient #9's "Hospice Plan of Care" for certification period of 11/4/24 to 1/2/25 revealed a physician's order for a Hospice Aide 5-7 times a week for 9 weeks beginning the week of 11/4/24. Review on 12/31/24 of Patient #9's medical record revealed that there were supervisory visits completed for the Hospice Aide on 11/25/24 and 12/24/24. Further review of the medical record revealed that there was no supervisory visit performed on 12/11/24. Interview on 12/31/24 at 2:00 p.m. with Staff D (Director of Clinical Operations) confirmed that there was no supervisory visit performed for Patient #9 on 12/11/24.

Based on personnel record review and interview, it was determined that the facility failed to ensure that the hospice maintained and documented volunteer orientation for 1 of 1 volunteer personnel records reviewed. (Staff identifier is C.) --- Findings include: Review on 12/31/24 of Staff C's (Volunteer) personnel record revealed that Staff C started volunteering at the Hospice in 2019. Further review of Staff C's personnel record revealed that there was no documentation of orientation to the Hospice. Interview on 12/31/24 at approximately 1:20 p.m. with Staff A (Vice President of Human Resources) confirmed the above findings.

Based on review of personnel records, and interview it was determined that the facility failed to ensure that skills and competence were assessed for individuals annually for 1 out of 6 employees reviewed. (Staff identifier is B.) --- Findings include: Review on 12/31/24 of Staff B's (Medical Director) personnel record revealed the last annual review was completed on 12/17/21. Interview on 12/31/24 at approximately 1:30 p.m. with Staff A (Vice President of Human Resources) confirmed the above findings. Staff A also confirmed that the facility did not have written policies and procedures describing its method(s) of assessment of competency and maintain a written description of the in-service training provided during the previous 12 months.

Based on personnel record review and interview, it was determined that the facility failed to ensure a criminal background check was done on 1 out of 6 employees reviewed. (Staff identifier is B.) --- Review on 12/31/24 of Staff B's (Medical Director) personnel record revealed that Staff B's employment with the facility began on 9/19/11. Further review of Staff B's personnel record revealed that there was no criminal background check. Interview on 12/31/24 at approximately 1:20 p.m. with Staff A (Vice President of Human Resources) confirmed the above findings. Review on 12/31/24 of the facility policy titled, "Personnel Record Contents", Dated May 2021, revealed: "...Procedure, 1. The content of the personnel files for regular full or part-time personnel will include: ... P. Criminal background check..."