Every finding on record at Vnacare

Upon patient record review 1 of 19 (Patient #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 #11: The comprehensive assessment did not contain a complete assessment of spiritual needs related to terminal illness.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 4 of 19 (Patients #5,7,8,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: Med Profile indicates Miralax 17 gm powder with no diluent ordered. Corrected on site. Patient #7: Med Profile indicates Miralax 17 gm powder with no diluent ordered. The record reflects patient uses Duo-Neb Nebulizer, this is not reflected on MAR. Corrected on site. Patient# 8: Oxygen machine and Nebulizer machine was listed in DME Section of POC. No Nebulizer or Oxygen meds ordered or on medication list. Corrected on site. Patient #13: Med Profile indicates Norco 5-325 (Hydrocodone 5mg and Acetaminophen 325mg). The MAR indicates NTE 3mg (not 3gm) of Acetaminophen in 24 hours. Corrected on site.

Upon patient record review, 4 of 19 (Patients #5,7,8,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: Med order indicates Miralax 17 gm powder with no diluent ordered. Corrected on site. Patient #7: Med order indicates Miralax 17 gm powder with no diluent ordered. The record reflects patient uses Duo-Neb Nebulizer, this is not reflected on MAR. Corrected on site. Patient# 8: Oxygen machine listed in DME Section of POC. No Oxygen treatment ordered or on medication list. Corrected on site. Patient #13: Med order indicates Norco 5-325 (Hydrocodone 5mg and Acetaminophen 325mg). The MAR indicates NTE 3mg of Acetaminophen in 24 hours. Corrected on site.

Upon patient record review, 3 of 19 (Patients #1,2,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had a fall mat, wedge pillow, shower chair and ceiling lift. These items were not included on the Plan of Care. Corrected on Site. Patient #2: This patient had a FWW, hospital bed, raised toilet seat and shower chair. These items were not included on the Plan of Care. Corrected on Site. Patient #5: The record reflected that this patient had a FWW, nebulizer and oxygen. These DME items were not included on the Plan of Care. Corrected on S

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions for Infection Control for Bag Management (Policy 8.7). This policy indicates bag to be placed on clean surface or hung from clean surface, and/or when visit completed reusable equipment is cleaned using alcohol or soap +water. Patient #1: The RN did not prepare chair in room prior to setting her nursing bag onto the chair seat surface. Patient #3:The RN did not prepare chair in room prior to setting his nursing bag down onto chair seat surface. Additionally, he did not clean equipment (stethoscope, O2 sat) after use and used gloved hands to gather items from his bag after patent care had begun.

Upon personnel record review, 1 of 13 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: Personnel #8: The Aides Initial Competency did not have required observed/demonstrated skills for the following: · Normal range of motion and positioning · Bed bath · Sponge, tub, and shower bath

Upon patient record review 1 of 19 (Patient #13) 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 Patient #13: The POC listed Aide visit frequency of 2 X's per week for Benefit Week 12/24/23 however, the second scheduled visit on 12/29/23 was not completed.

Upon patient record review, 8 of 19 (Patients # 3,7,9,10,11,12,15,19) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.