Every finding on record at Vnn Hospice Services Inc

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: SOC 12/6/2024, SW assessment occurred 12/9/2024, identified no mortuary plans. No evidence on POC for problem/goals/interventions for mortuary planning. Corrected on site. Patient #2: SOC 12/5/2024, SW assessment occurred 12/9/2024, identified no mortuary plans. No evidence on POC for problem/goals/interventions for mortuary planning. Corrected on site. Patient #3: SOC 12/3/2024, SW assessment occurred 12/6/2024, identified no mortuary plans. SN assessment 12/3/2024 identified Braden score of 10-high risk and fall risk 11-high risk. No evidence on POC (last POC update 12/20/2024) for problem/goals/interventions for mortuary planning, fall risk or skin integrity. Corrected on site. Patient #5: SOC 10/7/2024, SW comprehensive assessment occurred 12/5/2024, identified no mortuary plans. No evidence on POC(last POC update 12/20/2024) for problem/goals/interventions for mortuary planning. Corrected on site.

Upon patient record review, 1of 5 (Patient #5) 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 #5: Fall risk identified by SN and on updated POC as of 12/20/2024, last update on aide assignment was 11/12/2024. No evidence of falls risk on aide assignment sheet. Corrected on site.

Upon patient record review 1 of 5 (Patient #1) 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 #1: SOC order 12/6/2024 included aide 3x week. 12/15/2025 5 aide visits were made with no evidence of an order increasing frequency. Week of 12/22/2024 one visit made 12/23/2024 with no evidence of missed visits.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS

Upon patient record review, 2 of 14 (Patient #7,9) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS Patient 9: Patient consents signed by patient's POA. There is no evidence of full signature on all pages of the consents. This is evidenced by signature lines with initials only on 4/10 signature pages. COS

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS

Upon patient record review, 2 of 14 (Patient #7,9) did not have evidence of the appropriate documentation for release of confidential information. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS Patient 9: Patient consents signed by patient's POA. There is no evidence of full signature on all pages of the consents. This is evidenced by signature lines with initials only on 4/10 signature pages. COS

Upon patient record review, 2 of 14 (Patient #7,9) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS Patient 9: Patient consents signed by patient's POA. There is no evidence of full signature on all pages of the consents. This is evidenced by signature lines with initials only on 4/10 signature pages. COS

Upon patient record review, 2 of 14 (Patient #7,9) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS Patient 9: Patient consents signed by patient's POA. There is no evidence of full signature on all pages of the consents. This is evidenced by signature lines with initials only on 4/10 signature pages. COS

Upon patient record review, 14 of 14 (Patient #1-14) 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. Patients 1-14: All patient records reviewed: Despite the presence of an initial bereavement assessment in all records, none of the bereavement assessments included a focus on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: There is evidence in the medical record that the patient had a wound on admission. There is evidence in the medical record that the wound was assessed three times between 10/03/2024 and 10/26/2024 but no evidence the wound was assessed after 10/26.

Upon patient record review, 8 of 14 (Patient #1,2,4,5,7,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: Identified on assessment: depression; pain; failure to thrive; dependence on oxygen; confusion; dysphagia. There is no evidence of these plans of care including problems, goals, interventions. COS Patient 2: Identified on assessment: high risk for falls; order for daily Eliquis; dysphagia. There is no evidence of these plans of care including problems, goals, interventions. Patient 4: Identified on assessment: dysphagia; high risk for falls; presence of foley catheter. There is no evidence of these plans of care including problems, goals, interventions. Patient 5: Identified on assessment: aspirin for blood thinner; high risk for falls; dysphagia; high risk for skin breakdown AEB Braden score 12; presence of foley catheter. There is no evidence of these plans of care including problems, goals, interventions. COS. Patient 7: Identified on assessment: high risk for skin breakdown; dysphagia; high risk for falls. There is no evidence of these plans of care including problems, goals, interventions. Patient 8: Identified on assessment: High risk for skin breakdown; high risk for falls; presence of order for Eliquis; dysphagia. There is no evidence of these plans of care including problems, goals, interventions. Patient 9: Patient identified on assessment to be high risk for falls. There is no evidence of falls plan of care including problems, goals, and interventions. Patient 10: Identified on assessment: dependence on oxygen; high risk for falls. There is no evidence of these plans of care including problems, goals, interventions.

Upon patient record review, 8 of 14 (Patient #1,2,4,5,6,7,8,10) 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: DME need identified on assessment: hospital bed with APP, overbed table, wheelchair, bedside commode, oxygen, nebulizer. No evidence on the plan of care: bedside commode, nebulizer. COS Patient 2: DME need identified on assessment: hospital bed with APP, egg crate mattress, overbed table, wheelchair, oxygen, nebulizer. No evidence on the plan of care: egg crate mattress, hospital bed, oxygen. COS Patient 4: DME need identified on assessment: hospital bed with APP, overbed table, oxygen, nebulizer. No evidence on the plan of care: APP. COS Patient 5: DME need identified on assessment: hospital bed with APP, overbed table, wheelchair, oxygen, nebulizer. No evidence on the plan of care: wheelchair. COS Patient 6: DME need identified on assessment: hospital bed, overbed table, wheelchair, oxygen, nebulizer. No evidence on the plan of care: wheelchair. Patient 7: DME need identified on assessment: hospital bed with APP, bedside commode, overbed table, wheelchair, shower chair, oxygen, nebulizer. No evidence on the plan of care: wheelchair, bedside commode, shower chair. COS Patient 8: DME need identified on assessment: hospital bed with APP, overbed table, walker, wheelchair, oxygen, nebulizer, shower chair. No evidence on the plan of care: wheelchair, shower chair. COS Patient 10: DME need identified on assessment: hospital bed with APP, overbed table, walker, wheelchair, oxygen, nebulizer, shower chair. No evidence on the plan of care: APP, shower chair. COS

Upon patient record review, 10 of 14 (Patient #1,2,3,5,6,7,8,9,10,11) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 11: Patient on service 09/21/2024-09/24/2024. There is no evidence that this patient was discussed in IDT.

Upon patient record review, 4 of 14 (Patient #1,2,7,8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1: There is evidence in the medical record that IDG notes incomplete on 10/25/2024. SC and MSW notes do not summarize care provided previous 2 weeks, or outline plan for next 2 weeks. Patient 2: There are incomplete IDG notes from MSW on dates: 02/02/2024, 02/16/2024, 03/15/2024, 04/26/2024, 07/05/2024. Notes do not summarize care provided previous 2 weeks, or plan for next 2 weeks. There are incomplete IDG notes from MSW and SC on dates: 03/01/2024, 03/29/2024, 06/07/2024. This is evidenced by the notes do not summarize care provided previous 2 weeks, or plan for next 2 weeks. Patient 7: 07/19/2024 IDT has no evidence of an RN note entered. On IDT dates 08/16/2024, 08/30/2024, 09/13/2024 there is evidence in the medical record that IDG notes for SC incomplete as evidenced by the notes do not summarize care provided previous 2 weeks, or plan for next 2 weeks. On IDT dates 08/16/2024, 08/30/2024, 09/13/2024, 09/27/2024, 10/11/2024, 10/25/2024; there is evidence in the medical record that MSW IDG notes incomplete as evidenced by the notes do not summarize care provided previous 2 weeks, or plan for next 2 weeks. Patient 8: There is evidence in the medical record that IDG notes for SC and MSW incomplete on 08/30/2024 as evidenced by the notes do not summarize care provided previous 2 weeks, or plan for next 2 weeks.

Upon patient record review, 2 of 14 (Patient #2,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: SN visit frequency order is once weekly and 3 visits as needed. Between dates: 06/26/2024 – 07/09/2024, 08/13/2024 -08/26/2024, 10/22/2024 – 11/6/2024; there is no evidence in the medical record of a SN visit made. Patient 5: SN visit frequency order is once weekly and twice weekly as needed. There is no evidence of a SN visit made between 10/30/2024 and 11/11/2024. There is an 11/11/2024 RN visit; however, this visit is blank.

Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 1: There is evidence in the medical record that the RN assessed hypoxia during the initial assessment visit on 10/03/2024. During follow up visit on 10/04/2024, there is evidence in the medical record that the RN assessed hypoxia; loud, pounding heart sounds; and wheezing with rapid respiratory rate. There is no evidence of documentation that the RN reported these findings to the physician. There are scanned documents dated 07/23/2024, 08/31/2024, and 10/11/2024. These scanned documents are all lab reports. There is no evidence in the medical record that these lab results were reported to the physician. Patient 2: There is evidence in the medical record that the RN assessed hypoxia on 12/19/2023 and 03/16/2024. There is no evidence of documentation that the RN reported these findings to the physician.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 7 of 14 (Patient #2,3,4,5,6,8,9) 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 2: Aide care plan with following task ordered with no evidence of frequencies: feeding assist; dressing; record BM; turn and reposition; bedbound; bed to chair; bedrails up. It is also noted that there is no evidence of bleeding precautions on the aide care plan. COS Patient 3: Aide care plan with following task ordered with no evidence of frequencies: record BM; turn and reposition; bedbound; chair to bed; change patient’s linen. It is also noted that there is no evidence of vital signs parameters on the aide care plan. COS Patient 4: There is a physician’s frequency order for nurse aide visits on the plan of care. There is no evidence of an aide care plan. COS Patient 5: Aide care plan with following task ordered with no evidence of frequencies: dressing; record BM; change patient’s linen; 1 bedrail up; measure urinary output. Patient 6: Aide care plan with following task ordered with no evidence of frequencies: record BM; turn and reposition; change patient’s linen; chair to bed. It is also noted that there is a disclaimer in the shower section of the aide care plan stating that if patient is too weak for a shower, aide may perform bed bath. COS Patient 8: There is no evidence of bleeding, aspiration, or oxygen precautions on the aide care plan. Patient 9: There is evidence of aspiration precautions on the aide care plan. There are no aspiration precautions documented on the patient's plan of care.

Upon patient record review 3 of 14 (Patient #1,2,4) 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 1: Physician’s aide visit frequency order is 5 times weekly. Order was written on 10/03/2024 with same start date. The only aide visit made that week was on 10/04/2024. Patient 2: Physician’s aide visit frequency order is 5 times weekly. The most recent aide visit documented in the medical record is dated 10/28/2024. Patient 4: Physician’s aide visit frequency order is 5 times weekly written 11/07/2024. There are no aide visits documented in the patient’s medical record. COS-order discontinued 11/13/2024.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 7: Patient consents signed by patient's daughter/POA. There is no evidence of full signature on all pages of all consents. This is evidenced by signature lines all containing a first name only. COS

Upon patient record review, 8 of 14 (Patient #1,2,3,5,7,8,9,10) 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. Patients 1,2,3,5,7,8,9,10: There is evidence in medical records of copy/pasted MSW IDG notes. Copy/pasted notes during time period 01/12/2024 to 11/08/2024. Not only is there evidence of notes being copied from one IDG to another within the same patients’ charts; there is also evidence of notes being copied and pasted between patient charts (example: 11/08/24 MSW IDG note is identical between patients 3,5,6,8).

Upon inpatient contract review, 1 of 1 (Royal Springs-SNF contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon SNF/NF contract review, 1 of 1 contract (Royal Springs-SNF Contract) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

Upon SNF/NF contract review, 1 of 1 contract (Royal Springs-SNF Contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon patient record review, 1 of 5 (Patient #1) did not contain a current/comprehensive Medication Profile. During a Surveyor attended home visit, it was determined the patient is on a continuous flow of Oxygen, however, this was not on the current Medication Profile.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #3: Based on the Policy titled "Wound Care" ..."Nurse will document the wound stage and size on her progress notes", and ..."the nurse will document the progress of the wound and re-evaluate the effectiveness of the intervention/treatment at a minimum of every two weeks..." There was no documentation to indicate the wound was assessed during the month of October, in that, there was no mention of drainage, status of the wound bed, or measurements.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The Physician ordered Chaplain Services 1 x month. There was no Chaplain visit for the month of September.

Upon patient record review 3 of 4 applicable (Patients #1, #4 and #5) did not have evidence documentation in the patient record that a hospice aide provided services that were ordered by the IDG and included in the plan of care. Patient #1: During the second benefit period, the RN assigned the Aide to conduct a shower during all Aide visits. On the visits conducted on 9/28/2021, 11/2/2021 and 11/9/2021 the Aide documented a bed bath instead. Patient #4: During the visits conducted on 6/4/2021, 6/17/2021, 6/30/2021, 7/7/2021, and 7/8/2021, the Aide documented "Applied lotion" which was not part of the Aide Care Plan. Patient #5: Had Aide visits ordered by the Physician at a frequency of 3x week. There were no Aide visits conducted during the week of 5/2/2021.