Every finding on record at VNA of Orange County, LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, that address the minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) of start of care records reviewed it was revealed that the organization did not ensure that the records included the minimum information required to facilitate patient evacuation and transportation. Clinical Record 2: The patient was admitted to hospice services on 06/07/2024 with a terminal diagnosis of malignant neoplasm of the accessory sinus and revoked services on 06/11/2024. A concurrent review of the clinical record and interview with the Director of Patient Care Services (DPCS) on 11/14/2024 revealed that the record did not include a documented emergency plan including minimum information to facilitate patient evacuation and if the patient had life-dependent equipment that would need to be considered in an emergency. The DPCS stated, "This patient was in an SNF so we definitely should have documented a coordinated plan for supporting the safe evacuation of this patient. I get it." Clinical Record 10: The patient was admitted to hospice services in Benefit Period 1 effective 10/03/2024-12/31/2024 with terminal and pertinent diagnoses that included Secondary malignant neoplasm of the right lung, COVID-19, and oxygen dependence. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and how much supplemental oxygen would be required for the oxygen-dependent patient. "The plan of care indicated that an emergency plan was established but you are correct that there is no place in the patient's clinical record that there is an emergency plan documented." Clinical Record 11: The patient was admitted to hospice services in Benefit Period 10 on 10/23/2024-12/21/2024 with terminal and pertinent diagnoses that included hypertensive heart disease with heart failure, history of falls, TIA, COPD, and oxygen dependence. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include a documented emergency plan that included minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and how much supplemental oxygen would be required for the oxygen-dependent patient. Clinical Record 13: The patient was admitted to hospice services on 09/05/2024-12/03/2024 in Benefit Period 1 with terminal and pertinent diagnoses that included end-stage cardiac disease, AFIB, Parkinsonism, and Myelodysplastic Syndrome. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include a documented emergency plan that included minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and any life-dependent equipment such as supplemental oxygen.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) of hospice aide personnel files reviewed it was revealed that the organization did not ensure that an annual on-site visit was performed and documented. Personnel Record 8: The hospice aide was hired on 12/16/2004. The Administrator confirmed that the personnel file included no record of a documented annual on-site visit to observe the aide while she was performing care in 2023 or thus far in 2024. The Director of Patient Care Services (DPCS) stated, "I know the RNs see the aides all of the time, sometimes they even do joint visits together. I guess it was just never documented." The Administrator stated, "We have it scheduled for the RN and the Aide to do a visit together next week."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 5 of 9 (56%) of personnel records reviewed for personnel providing care, the organization did not ensure that the skills and competencies were completed annually in accordance with the organization's policies and procedures. The Competency Program Policy, recently revised in December 2018, stated in part, "...After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process. ...Clinical competency of qualified evaluators (preceptors, supervisors, peers, clinical specialists) will also be defined and regularly evaluated. ..." Personnel Record 4: The MSW/Bereavement Coordinator was hired on 11/03/2020. The Administrator confirmed on 11/14/2024 that the assessment of skills and competencies of the Social Worker for the MSW role and the Bereavement Coordinator role had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented documents titled "annual competency assessment skills checklist social worker" and "annual competency assessment skills checklist bereavement coordinator" with the self-assessments completed by the social worker/bereavement coordinator dated 11/12/2024. The Administrator stated, "We'll be getting this completed going forward but we don't have any completed in the past couple of years." Personnel Record 5: The Chaplain was hired on 01/05/2022. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the Chaplain had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled "annual competency assessment skills checklist Chaplain" with the self-assessment completed by the Chaplain dated 11/13/2024. The Administrator stated, "We'll be getting this completed going forward but we don't have any completed in the past couple of years." Personnel Record 6: The Volunteer Coordinator was hired on 08/02/2021. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the Volunteer Coordinator had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled "annual competency assessment skills checklist Volunteer Coordinator" with the self-assessment completed by the RN dated 11/14/2024. The Administrator stated, "We'll be getting this completed going forward but we don't have any completed in the past couple of years." Personnel Record 8: The Hospice Aide was hired on 12/16/2004. The Administrator confirmed on 11/14/2024 that the assessment of skills and competencies of the Aide had not been performed annually as required by organizational policy in 2023, or to date in 2024. "We will absolutely do that right away but don't have anything documented to provide you today." Personnel Record 9: The Registered Nurse (RN) was hired on 12/09/2013. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the registered nurse had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled "annual competency assessment skills checklist Registered Nurse" with the self-assessment completed by the RN dated 11/14/2024. The Administrator stated, "We'll be getting this completed going forward but we don't have any completed in the past couple of years."

It is required that the Interdisciplinary Group documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) of death records reviewed, the organization did not ensure that the disposal of controlled medications was discussed and documented as required by organizational policy and procedure. Medication Management and Disposal of Controlled Substances patient/caregiver teaching sheet with a revision date of 09/2020 stated in part, "The hospice nurse, social worker, or chaplain attending the death of the hospice patient shall inform the family/caregivers of their responsibility to dispose of all the patient's prescribed medications and shall document this instruction in a clinical note. ..." Clinical Record 3: The patient was admitted to hospice services on 10/11/2023, entered into Benefit Period 4 effective 06/07/2024-08/05/2024, and died on 06/12/2024 in a private residence. During concurrent clinical record review and interview with the DPCS on 11/14/2024, it was revealed that the RN who attended the patient's death did not document that she informed the patient's family of their responsibility to dispose of all medications according to organizational policy and procedure. The DPCS stated, "Our LVNs typically attend deaths and always remember to document family instruction of medication and controlled substance disposal but our RNs are not used to doing it as much. I'm sure she did it but forgot to document that she did it."

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 2 (100%) of clinical records reviewed for patients residing in a Skilled Nursing Facility (SNF), the organization did not ensure that the hospice plan of care specified which provider was responsible for performing the functions agreed upon and included in the plan of care. Clinical Record 2: The patient was admitted to hospice services on 06/07/2024 with a terminal diagnosis of malignant neoplasm of the accessory sinus and revoked services on 06/11/2024. A concurrent review of the clinical record and interview with the Director of Patient Care Services (DPCS) on 11/14/2024 revealed that the plan of care did not specify what functions the SNF was responsible for and what the hospice was responsible for. The DPCS stated, "We have a delineation of responsibilities document that admitting RN completes for all SNF patients and places in the facility binder. We don't bring it back and put it in our records though. I understand now that the plan of care would need to be the same in both places (the SNF and the hospice record)." Clinical Record 13/Home Visit 2: The patient was admitted to hospice services on 09/05/2024-12/03/2024 in Benefit Period 1 with terminal and pertinent diagnoses that included end-stage cardiac disease, AFIB, Parkinsonism, and Myelodysplastic Syndrome. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the plan of care did not specify what functions the SNF was responsible for and what the hospice was responsible for. During the home visit with the hospice aide (Personnel Record 8) the patient's folder was reviewed which contained a document that included a delineation of responsibilities section that did not specify what functions the SNF was responsible for and what the hospice was responsible for. The document indicated the frequency of visits provided by the Hospice SN, MSW, Chaplain, and Aide.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. THIS IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 8 (13%) clinical records reviewed revealed the hospice did not ensure social worker visits followed the visit frequencies assigned in the plan of care and/or physician's orders. Record #95404 was reviewed and revealed the social worker visit frequency of two times a month. Review of clinical record revealed one missing social worker visit the month of March 2022. During interview on 5/9/22, the Operations Manager and Administrator stated they could not locate the missing social worker visit and/or physician's orders/plan of care for the missing social worker visit.

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 interview and clinical record review. 1 of 5 (20%) applicable clinical records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the aide was compliant with the ordered visit frequency included in the plan of care. Record #79905 was reviewed and revealed the Hospice Aide visit frequency of two times a week for the week of 4/24/22. The clinical record was missing a hospice aide visit the week of 4/24/22. Additionally, the Hospice Aide visit frequency was three times a week starting 5/1/22 and review of the clinical record revealed a missing hospice aide visit the week of 5/1/22. During interview on 5/9/22, the Operations Manager and Administrator stated they could not locate the missing hospice aide visits and/or physician's orders/plan of care for the missing hospice aide visits.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed no less frequently than every 15 days. This standard was not met as evidenced by record review and interview. 1 of 11 (9%) patient records reviewed revealed that the update of the comprehensive assessment was not completed within 15 days according to CMS 418.54(d) or within 21 days according to the CMS “blanket” waivers. Agency policy 1-014 Comprehensive Assessment revised 10/2019 stated in part “The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum every 15 days.” CMS Hospice Federal Blanket Waiver effective March 1, 2020, until the removal of the public health emergency, stated in part “Hospices continue to complete the required comprehensive assessments and updates, the timeframes for updating the assessment may be extended from 15 to 21 days.” Patient #56766: The update of the comprehensive assessment was documented on 10/6/21. The next update was documented on 11/3/21 (28 days later). Record review and interview with the CEO/Administrator and Director of Education (RN)) on 12/17/21 confirmed this finding. The CEO stated she was in contact with their electronic medical record company to see if there was an error on their part.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by record review and interview. Four of 11 (36%) patient record failed to provide documentation that the hospice followed the individualized plan of care. Agency policy 1-006 Care/Service Coordination stated in part “the case manager will be responsible for cooperative care planning in order to assure that goals, action, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services.” Patient #56766: hospice certification period 10/13/21-1/10/22. The skilled nurse (SN) visit frequency was ordered 2 times a week. There was a skilled nurse visit (SNV) documented on 11/15/21. The record failed to provide documentation of a second visit the week of 11/14/21. Patient #49440: hospice certification period 11/16/21-1/14/22. The SN visit frequency was ordered 2 times a week. There were skilled nursing visits documented on 12/1/21 and 12/7/21. The record failed to provide documentation of a second visit for the weeks of 11/28/21 and 12/5/21 respectively. Patient #21382: hospice certification period 8/16/21-11/13/21. The SN visit frequency was ordered 2 times a week. There was a SNV documented on 11/9/21. The record failed to provide documentation of a second SNV the week of 11/7/21. Patient #56772: hospice certification period 9/21/21-12/19/21. The SN frequency was ordered 2 times a week. There was a SNV dated 10/22/21. The record failed to provide documentation of a second SNV the week of 10/17/21 Record review and interview with the CEO/Administrator and Director of Education (RN)) on 12/17/21 confirmed this finding. The Director of Education stated that some of the missed visits may not have been dated correctly.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by observation and interview. Two of 3 (67%) patients who received a home visit with observation of hand hygiene and safe handling of equipment revealed the hospice organization did not ensure adherence to agency infection prevention and control policies and procedures. The Clinician Bag Technique and Care of Equipment procedure signed by [Staff # 92262] on 11/16/20 states in part “Handwashing must occur before entering & re-entering the bag for any reason.” The Clinician Bag Technique and Care of Equipment procedure signed by [Staff # 92262] on 11/16/20 also stated “All items removed from the bag must be cleaned before returning to the bag.” Patient #65234: During a home visit on the RN, Staff #92262 was observed re-entering the visit bag to remove a stethoscope without washing her hands. Observation revealed RN, Staff #92262 did not clean the stethoscope prior to it being placed back in the visit bag. Patient #56772: During a home visit on 12/16/21 at 1115, the RN, Staff #92262 was observed to enter the visit bag, remove equipment, and begin patient care without washing her hands. Observation revealed RN, Staff #92262 did not clean the BP cuff and stethoscope prior to being placed back in the visit bag. The CEO/Administrator and Director of Education (RN) were interviewed on 12/16/21 after the home visit and acknowledged that [Staff #92262] may have been nervous but should have washed her hands prior to patient care and entering/re-entering bag as well as cleansed the equipment before putting it back in visit bag.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by record review and interview. Six of 11 (55%) patient records were missing evidence that spiritual counseling services were provided when orders for visits were present on patient plans of care. Record #49440 - election of hospice benefit dated 11/16/21 and orders were present for spiritual counseling visits to be made. Record #58702 - election of hospice benefit dated 11/8/21 and orders were present for spiritual counseling visits to be made. Record #65234 - election of hospice dated 11/10/21 and orders were present for spiritual counseling visits to be made. Record #87425 - election of hospice benefit dated 7/7/21 and orders were present for spiritual counseling visits to be made. Record #44272 - election of hospice benefit dated 7/21/21 and orders were present for spiritual counseling visits to be made. Record #93832 - election of hospice benefit dated 11/2/21 and orders were present for spiritual counseling visits to be made. Interview with the CEO/Administrator on 12/15/21 confirmed that spiritual care visits were not completed by a spiritual counselor when spiritual care services where ordered on plans of care. They also stated that the hospice was not able to consistently provide spiritual care for “a couple of months” due to the chaplain being out on an intermittent leave of absence. However, they currently have a RN with a divinity degree who became available “10-12 days ago” to provide spiritual care visits and services as desired by patients.