Every finding on record at Vsl Vetter Home Health Care of Gering LLC

Based on record review, policy and procedure review, observation of the provision of care, and staff interview, the hospice failed to ensure the patients medication profile (form used by the agency to provide real-time list of medications utilized by the patient) included all medications initiated between assessment periods for 6 of 19 (Patient 1, 5, 6, 7, 8, and 12) records reviewed and the hospice failed to have a process to ensure standing orders (physician pre-approved, nurse-initiated protocols designed to manage symptoms promptly at the end of life) were incorporated into the medication profile once initiated.  The census was 18. --- Findings are: A. Review of the agency policy and procedure titled Medication Profile, Policy No. 4-050.1, revised 11/2021, revealed:1. The medication profile will be updated for each change to reflect current medication, and new and/or discontinued medications. 2. The medication profile will be used as a care planning tool to ensure the patient, family/caregiver, and other clinicians understand the medication regime. 3. The medication profile is a communication tool for all other clinicians involved in the patients care. 4. A drug regime review will be completed upon initial assessment, comprehensive assessment, when updates occur, and with the addition of new medications. 5. The policy did not include a process to ensure staff were aware that medications/treatments from standing orders were to be included on the medication profile once initiated by the nurse.  B. Review of Patient 1's clinical record revealed:1. A skilled nurse (SN) note dated 1/2/26. The SN documented that the patient received new eye drops for glaucoma.2. The new eye drop order was not included in the patient's medication profile. C. A home visit to the home of Patient 1, conducted on 2/23/24 at 2:30 PM, revealed a vial of Rhopressa eye drops. The patient confirmed these as the "new eye drops" that were ordered by the [patient's] eye doctor for glaucoma (patient was not able to recall the date the physician ordered the eye drops).  D. Review of Patient 5's clinical record revealed:1. A SN note dated 2/15/26. The SN documented new orders received to start Zofran (an anti-nausea medication) 4 milligrams (mg) by mouth (po) every 6 hours, and acetaminophen 650 mg po every 4 hours as needed for fever greater than 100.4.2. The new orders for Zofran and acetaminophen were not included in the patient's medication profile.  E. Review of Patient 6's clinical record revealed:1. A SN note dated 1/27/26. The SN documented the patient's scopolamine patch (used to treat nausea) was changed from routine to as needed. 2. Scopolamine frequency was not updated on the patient's medication profile.  F. Review of Patient 7's clinical record revealed:1. A SN note dated 2/2/26. The SN documented the patient's caregiver reports administering Miralax (a laxative) every day and occasionally administering a suppository for bowel care. 2. A SN note dated 2/16/26. The SN documented the patient's caregiver reports administering Miralax (a laxative) two times per day but will reduce to 1 time per day due to the patient having loose stools now.  3. Miralax and bowel suppository orders were not included on the medication profile when initiated, the changes verbalized by the caregiver on 2/2/26 and 2/16/26 were not updated on the medication profile.  G. Review of Patient 8's clinical record revealed:1. A SN note dated 2/4/26. The SN documented orders were received to discontinue Miralax, start senna-d (used for constipation and softening stools), and to schedule Zofran every 6 hours.2. The Miralax and Zofran orders were not updated on the medication profile.  H. Review of Patient 12's clinical record revealed:1. A SN note dated 2/19/26. The SN documented Fentanyl patch (a pain medication patch applied to the skin to release medicine over a specified time) was applied today.2. Fentanyl was not on the patient's medication profile.  I. During an interview on 2/25/26 at 5:00 PM, the Administrator confirmed the medication profile for Patient 1, 5, 6, 7, 8, and 12 was not updated when orders changed, started, or discontinued, and the hospice failed to have a process to ensure standing orders were incorporated into the medication profile once initiated.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure the registered nurse (RN) conducted a visit to the home of 2 of 3 patients (Patient 4 and Patient 14) who received hospice aide services every 14 days, to assess the quality of the hospice aide (HA) services and ensure the needs of the hospice patient were being met. The total sample size was 19. The census was 18. --- Findings are: A. Review of the policy and procedure titled Home Health Aide Supervisory Visit, revised 11/1/25, revealed:1. The RN will complete supervisory visits and document appropriately.2. The RN must visit the patient's home no less frequently than every 14 days.3. The policy does not include the requirement that the RN is to assess the quality of care and services provided to the hospice patient, and to ensure the services are meeting the needs of the hospice patient, every 14 days.  B. Review of Patient 4's clinical record revealed:1. The Plan of Care for the certification period of 1/22/26 through 4/21/26 included orders for HA two times per week to provide a bed bath, and to change linens as needed. 2. The first HA visit occurred on 1/27/26.3. There was no visit by an RN to assess the quality of the HA services and ensure the needs of the hospice patient were being met from 1/27/26 through record review date of 2/24/26.  C. Review of Patient 14's clinical record revealed:1. The Plan of Care for the certification periods of 9/30/25 through 12/28/25 and 12/29/25 through 3/28/26 included orders for HA services 1 time per week to assist with bathing and linen changes. 2. There was no visit by an RN to assess the quality of the HA services and ensure the needs of the hospice patient were being met from 12/18/25 through 1/7/26 and from 1/22/26 through record review date of 2/24/26.  D. During an interview on 2/25/26 at 5:00 PM, the Administrator confirmed he hospice failed to ensure the RN conducted a visit to the home of Patient 4 and Patient 14  every 14 days, to assess the quality of the HA services and ensure the needs of the hospice patient were being met.

Based on record review, policy and procedure review, and staff interview, the hospice failed to provide day-to-day administrative or direct patient care by volunteers to equal at least 5% of the total direct patient care hours provided by the hospice employees for 2024 and 2025 and to date for 2026. The census was 18. --- Findings are:A. Review of the hospice policy and procedure titled Volunteer Services, Policy N. 4-007.1, revised 11/2021 revealed the agency was to provide volunteer services to provide support to the patient and family/caregiver in an amount that exceeds 5% of the total patient care hours of paid and contracted hospice personnel.  B. Review of the hospice's cost-savings report for 2024 and 2025 provided by the agency administrator revealed 0% volunteer usage. C. During an interview on 2/25/26 at 8:30 AM, the Volunteer Coordinator confirmed there has been no volunteer usage to date for 2026. D. During an interview on 2/25/26 at 9:30 AM, the Administrator confirmed volunteer usage for 2024 and 2025 was 0%, and 0% to date for 2026.

L523 Based on record review, policy and procedure review, job description review, and staff interview, the hospice failed to ensure the Spiritual Care Coordinator (SCC) and/or the Social Worker (SW) completed a comprehensive assessment of the patient and family's spiritual, emotional, and psychosocial needs no later than 5 days after the patient's election of hospice care for 12 of 19 patient records reviewed (Patient 1, 3, 5, 6, 7, 8, 9, 10, 11, 13, 14, and 15). The census was 23. This same deficiency was cited during a recertification survey completed on 2/20/20. Failure of the SCC and SW to complete a timely assessment of the patient and family's spiritual and psychosocial needs provided the opportunity for a delay in initiating interventions to address the patient and family's spiritual, emotional, and psychosocial needs. --- Findings are: Cross reference to L523

Based on record review, policy and procedure review, job description review, and staff interview, the hospice failed to ensure the Spiritual Care Coordinator (SCC) and/or the Social Worker (SW) completed a comprehensive assessment of the patient and family's spiritual, emotional, and psychosocial needs no later than 5 days after the patient's election of hospice care for 12 of 19 patient records reviewed (Patient 1, 3, 5, 6, 7, 8, 9, 10, 11, 13, 14, and 15). The census was 23. --- Findings are: A. Review of the hospice's policy and procedure titled Initial and Comprehensive Patient/Family Assessment, revised 8/2017, revealed the hospice interdisciplinary team must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care to identify the physical, psychosocial, emotional, spiritual, and bereavement needs. B. Review of the SW job description revealed the SW was responsible for completing and documenting an initial and ongoing assessment of the patient and family psychosocial needs. C. Review of the SCC job description revealed the SCC was responsible for ensuring an assessment of the patient and family's spiritual needs. D. Review of Patient 1's clinical record revealed: 1. An election of benefits form dated 1/27/23. 2. A spiritual care initial comprehensive visit completed 2/8/23 (12 days after the election of benefits). 3. There was no documentation of a Social Work visit completed as of 2/17/23 (21 days after the election of benefits). 4. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SCC and SW assessments. E. Review of Patient 3's clinical record revealed: 1. An election of benefits form dated 11/23/22. 2. A spiritual care initial comprehensive visit completed 11/30/22 (10 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SCC assessments. F. Review of Patient 5's clinical record revealed: 1. An election of benefits form dated 12/9/22. 2. There was no documentation of a SW visit completed until 1/10/23 (32 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. G. Review of Patient 6's clinical record revealed: 1. An election of benefits form dated 12/4/22. 2. There was no documentation of a SW visit completed until 1/25/23 (53 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. H. Review of Patient 7's clinical record revealed: 1. An election of benefits form dated 1/28/23. 2. There was no documentation of a SW visit completed as of 2/17/23 (20 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. I. Review of Patient 8's clinical record revealed: 1. An election of benefits form dated 2/8/23. 2. There was no documentation of a SW visit completed as of 2/17/23 (9 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. J. Review of Patient 9's clinical record revealed: 1. An election of benefits form dated 1/20/23. 2. There was no documentation of a SW visit completed as of 2/17/23 (28 days after the election of benefits). 3. A spiritual care initial comprehensive visit completed 1/30/23 (10 days after the election of benefits). 4. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW and SCC assessments. K. Review of Patient 10's clinical record revealed: 1. An election of benefits form dated 1/11/23. 2. There was no documentation of a SW visit completed as of 2/17/23 (37 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. L. Review of Patient 11's clinical record revealed: 1. An election of benefits form dated 12/22/22. 2. A SW visit was completed on 1/13/23 (22 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. M. Review of Patient 13's clinical record revealed: 1. An election of benefits form dated 1/25/23. 2. There was no documentation of a SW visit completed as of 2/17/23 (23 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. N. Review of Patient 14's clinical record revealed: 1. An election of benefits form dated 12/28/22. 2. There was no documentation of a SW visit completed as of 2/17/23 (51 days after the election of benefits). 3. A spiritual care initial comprehensive visit completed 1/16/23 (19 days after the election of benefits). 4. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW and SCC assessments. O. Review of Patient 15's clinical record revealed: 1. An election of benefits form dated 1/4/23. 2. There was no documentation of a SW visit completed prior to the 2/10/23 revocation date (37 days after the election of benefits). 3. There was no documentation in the clinical record to reveal the patient or family requested a delay of or declined the SW assessments. P. During an interview on 2/17/23 at 12:10 PM, the hospice SW confirmed it was the responsibility of the SW to complete a comprehensive assessment of the patient and family's psychosocial needs no later than 5 days after the patients election of hospice care, and confirmed the assessment was to be documented in the patient's clinical record. Q. During an interview on 2/17/23 at 3:25 PM, Clinical Manager (CM) confirmed the SCC and SW did not complete a comprehensive assessment of the patient and family's spiritual, emotional, and psychosocial needs no later than 5 days after the election of benefits for Patient 1, 3, 5, 6, 7, 8, 9, 10, 11, 13, 14, and 15 in accordance with the hospice's policies and procedures. The CM also confirmed there was no documentation in these patient records to indicate the patient or family requested a delay in the spiritual and psychosocial assessments.R. Failure of the SCC and SW to complete a timely assessment of the patient and family's spiritual and psychosocial needs provided the opportunity for a delay in initiating interventions to address the patient and family's spiritual, emotional, and psychosocial needs.

Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, 1 of 4 staff (Staff B), observed during the provision of care to 1 of 4 patients (Patient 1), failed to performed appropriate hand hygiene, glove use, use of clean bag technique, and proper use of barriers during the provision of wound care according to the hospice's policies and procedures. The census was 23. --- Findings are: A. Review of the hospice's policy and procedure titled Hand Hygiene and Surgical Antisepsis, revised 05/2022, revealed: 1. Staff are to perform hand hygiene by using soap and water or by using an alcohol-based product when hands are visibly soiled, when caring for a person with a known infection, before and after direct patient contact, after contact with a patient's intact skin, after removing gloves, after contact with body fluids, non-intact skin, and wound dressings. 2. Gloves are not to be used to take the place of hand hygiene measures. 3. Gloves are to be changed when moving from a contaminated body site to a clean body site. 4. Gloves are not to be washed between uses. 5. Gloves are to be disposed of after careful removal to prevent contamination. B. Review of the hospice's policy and procedure titled Home Health Care Field Supplies and Storage, revised1/2017, revealed: 1. A home care bag was to be used to contain items necessary to conduct a home visit and for transporting of such items to prevent the potential spread of infection between and among staff and patients. 2. If staff are unable to carry a bag into a home due to unfavorable conditions, the staff was to carry supplies in a non-permeable disposable bag. 3. Hand hygiene must be performed prior to entering the bag. 4. Bags are to be placed on a clean surface with a barrier between the surface and the bag, cushioned surfaces are to be avoided. 5. All items necessary for care should be removed at once to reduce the number of entries into the bag. 6. Soiled items such as used dressings are to be disposed of properly. 7. All re-useable equipment is to be cleaned prior to returning to the bag. C. Review of Patient 1's clinical record included an order for skilled nursing 2 times per week with focus on medication management, skin integrity, incision healing and care to amputation site (left leg stump). D. During the observation of the provision of cares on 2/14/23 at 8:40 AM, Registered Nurse (RN) (Staff-B) failed to: 1. Carry equipment and supplies necessary for care and treatment of the patient during the home visit, in a supply bag when vital signs equipment (blood pressure cuff, thermometer, oximeter, used to measure oxygen levels) were carried in the nurse's lab jacket pocket. 2. Sanitize hands prior to each removal of equipment from the lab jacket pocket. 3. Place a barrier between the patient's bed and the vital signs equipment after use on the patient. 4. Place a barrier between the floor and wound cleanser bottle and clean wound dressing supplies. 5. Perform hand hygiene and change gloves after removing a soiled dressing from wounds on the patient's amputation site and prior to touching wound cleanser bottle and applying wound cleanser to a clean gauze pad to clean the patient's wounds. 6. Place a barrier between the floor and soiled dressings and supplies used during wound care. 7. Perform hand hygiene and change gloves after cleansing the patient's wounds and prior to applying clean dressings to the patient's wound. E. During an interview on 2/15/23 at 2:30 PM, the Clinical Manager (CM) confirmed Staff-B failed to follow the hospice's policies and procedures for proper hand hygiene, glove use, bag technique, and barrier use during the provision of cares to Patient 1.

Based on record review, policy and procedure review, and staff interview the hospice failed to document a bereavement assessment for the patient's survivors and develop a bereavement plan of care based on the bereavement needs identified, and failed to document bereavement services provided for 3 of 3 bereavement records reviewed (Patient 17, 18, and 19). Total sample size was 19. The census was 23. --- Findings are: A. Review of the hospice's policy and procedure titled, Hospice Bereavement Services Follow-up/Support, revised 4/2022, revealed: 1. Hospice services were to be offered to all survivors for up to one year following the patient's death. 2. The bereavement coordinator was to make contact with the bereaved to complete a comprehensive bereavement assessment and to discuss the bereavement services offered. 3. A bereavement plan of care based on the assessment was to be completed, initiated, and revised as needed. 4. Survivors may choose not to participate in bereavement follow-up services. 5. Follow-up documentation was to be based on the plan of care. B. Review of bereavement records for Patient 17 revealed: 1. The patient expired 1/22/22. 2. There was no documentation of a bereavement assessment of the survivors after the patient's death. 3. There was no documentation of a bereavement plan of care. 4. There was no documentation of bereavement services provided after 2/8/22. 5. There was no documentation the bereaved declined further bereavement services after 2/8/22. C. Review of bereavement records for Patient 18 revealed: 1. The patient expired 10/7/21. 2. There was no documentation of a bereavement assessment of the survivors after the patient's death. 3. There was no documentation of a bereavement plan of care. 4. There was no documentation of bereavement services provided after 11/23/21 through 6/24/22 when the bereaved denied need for further bereavement support. D. Review of bereavement records for Patient 19 revealed: 1. The patient expired 7/12/20. 2. There was no documentation of a bereavement assessment of the survivors after the patient's death. 3. There was no documentation of a bereavement plan of care. 4. There was no documentation of bereavement services provided. 5. There was no documentation the bereaved declined further bereavement services. E. During an interview on 2/17/23 at 1:00 PM, the Clinical Manager confirmed bereavement assessment, plan of care, and documentation was not completed as required by regulation and hospice policy for Patient 17, 18, and 19.

Based on record review, policy and procedure review, and staff interview, the hospice failed to complete a physician order for signature by the ordering physician when a verbal order was received for 3 of 19 clinical records reviewed (Patient 1, 9, and 15). The census was 23. --- Findings are: A. Review of the hospice's policy and procedure titled Hospice Physician Orders, revised 10/2022, revealed both telephone and written orders for medications are to be documented in the patient's clinical record. If a telephone order, a copy is to be sent to the ordering physician for signature and included in the clinical record. B. Review of Patient 1's clinical record revealed: 1. A HS RN Standard Visit form (a skilled nurse visit note) dated 2/2/23, the nurse documents that registered nurse (RN) wrote orders to discontinue wound dressing orders and apply betadine to the wound bed two times per day and to monitor for changes. 2. There was no documentation in the clinical record a physician order form for the new treatment described in the skilled nurse visit note was completed and sent to the ordering physician for signature. C. Review of Patient 9's clinical record revealed: 1. A HS RN Standard Visit form dated 1/27/23, the nurse documents the patient requested lorazepam (an antianxiety medication) to be scheduled. The nurse documents that the patient's physician agreed with scheduling of lorazepam. 2. There was no documentation in the clinical record a physician order form for the scheduled lorazepam, including the dose, route, frequency to be taken, was completed and sent to the ordering physician for signature. D. Review of Patient 15's clinical record revealed: 1. An HS RN PRN Visit form (a skilled nurse visit note for an as needed/extra visit) dated 1/7/23, the nurse documents that RN received orders for morphine. 2. There was no documentation in the clinical record a physician order form for the morphine, including the dose, route, frequency to be taken, was completed and sent to the ordering physician for signature. E. During an interview on 2/17/23 at 3:25 PM, Clinical Manager (CM) confirmed the skilled nurse documented in the skilled nurse visit note for patients 1, 9, and 15 a change in medication or treatment orders occurred for each patient. The CM also confirmed the skilled nurse failed to follow the hospice's policy and procedure to send a completed physician order form for the changes and send it to the patient's physician for signature.