Every finding on record at Westminster Canterbury of Lynchburg, Inc.

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. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. DOCUMENT 1: Hand Hygiene Policy and Compliance Program Policy stated, in part: "Indications for staff performing hand hygiene are: before and after direct patient care", and after any contact with contaminated materials." CLINICAL RECORD 1/HOME VISIT 1 : This patient elected the hospice benefit on 09/24/2025 with a terminal diagnosis of cerebrovascular disease. During the home visit observation on 02/18/2026 with the hospice aide (Personnel Record 1) with the RN Team Leader (Personnel Record 5), the hospice aide was observed to give a bed bath to the patient. The hospice aide was observed to cleanse the patient's rectal area and then reach up and touch her glasses without sanitizing her hands. During an interview conducted with the RN Clinical Team Leader on 02/18/2026 It was stated that the hospice aide did not follow the agency policy for hand hygiene.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 14 (21%) clinical record reviewed and in 1 of 3 (33%) home visit observations in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide prepared by the RN were specific and not generic. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 09/24/2024 with a terminal diagnosis of cerebrovascular disease. On 02/12/2026, the physician ordered wound care foam patch to left ankle bone and left foot for protection, and wound care add barrier cream to bottom daily and prn. The plan of care dated 02/12/2026-02/18/2026 ordered: "Aide 2x/week." The hospice aide care plan dated 12/12/2025 assigned the hospice aide the relevant task of "bed bath at every visit." The hospice aide care plan did not include instructions addressing the wound dressing on the foot should it become dislodged or wet during the bed bath. During the home visit on 02/18/2026 with the hospice aide (Personnel Record 1), the hospice aide was observed to provide the patient with personal care. A bandage was observed on the patient's left foot. CLINICAL RECORD 3: This patient elected the hospice benefit on 12/22/2025 with a terminal diagnosis of pulmonary fibrosis. The RN initial visit note dated 12/22/2025 documented the patient was utilizing a walker and wheelchair. The Medical Social Worker assessment dated 12/30/2025 stated the patient used a transport chair through most of their home to help conserve energy. The plan of care dated 12/22/2025-02/18/2026 ordered: "Aide 2x/week." The hospice aide care plan was reviewed for the dates of 12/22/-02/18/2026 and included directions to assist with transfer/ambulation every visit. There were no clear directions to use the transport chair/walker/wheelchair for transfers/ambulation. CLINICAL RECORD 7: This patient elected the hospice benefit on 02/06/2026 with a terminal diagnosis of lung cancer. The hospice plan of care was reviewed for the dates of 02/06/2026-02/18/2026 and included orders for hospice aide visits two times a week and the skilled nurse to wrap the legs with kerlix and ace bandages twice a week for edema. The hospice aide care plan was reviewed for the dates of 02/06/2026-02/18/2026 and assigned the HA the relevant task of a "bed bath at each visit". The hospice aide care plan did not include instructions addressing the kerlix and ace bandages on the legs should they become dislodged or wet during the bed bath. An interview was conducted with the RN Clinical Leader (Personnel Record 5) on 02/18/2026 and it was stated that the hospice aide care plans needed to be more complete.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records in which the patient received hospice aide services, the agency did not ensure that the registered nurse was notified of changes related to the hospice aide care plan. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/11/2025 with a terminal diagnosis of Alzheimer's Disease. The hospice plan of care dated 11/09/2025-02/06/2026 included orders for hospice aide visits two times a week. The hospice aide visit note dated 02/04/2026 included documentation that the following tasks were not performed as directed by the hospice aide care plan dated 11/09/2025-02/06/2026: assist with dressing every visit, assist with feeding every visit, oral hygiene every visit, shampoo hair every visit, shower every visit, skin care-apply moisture barrier every visit, and skin care-apply lotion every visit. In review of the hospice aide visit note and the nursing notes, there was no documentation present that the registered nurse was notified of these changes to the hospice aid care plan. During the joint review of the clinical record and interview, the RN Clinical Team Leader (Personnel Record 5) stated that there was no documentation present that stated the registered nurse was updated that the hospice aide care plan was not followed.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A joint review of the agency report to the Governing Body dated 02/12/2026 with the Volunteer Coordinator on 02/18/2026 revealed that the volunteer utilization was 1.4% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 02/18/2026, the Administrator stated that there had been a change in the Volunteer Coordinator position to allow the agency to focus on re-building the volunteer program. A joint review of the agency report to the Governing Body dated 02/12/2026 with the Volunteer Coordinator on 02/18/2026 revealed that the volunteer utilization was 1.4% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the medication profile included all of the patient's current prescription and OTC drugs. Clinical Record 9: The start of care comprehensive assessment completed by the Registered Nurse on 03/28/2023 and the hospice plan of care stated the patient was utilizing Oxygen at 5 liters per minute via nasal cannula. Oxygen was not included on the medication profile as of 4/13/2023. During an interview on 04/13/2023, the Administrator reviewed the associated clinical record and stated Oxygen had been inadvertently omitted from the medication profile and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 7 of 14 (50%) clinical records reviewed, revealed the agency did not ensure that the plan of care included documentation of the drugs and treatment necessary to meet the needs of the patient. Clinical Record 1: The 01/23/2023 Hospice plan of care (POC) stated, "Facility to manage 18 French 10cc suprapubic foley", however there were no orders related to foley care or management included in the POC. The 01/23/2023 POC included the medication, "Meclizine HCL by mouth 25 mg 1 tab daily as needed." There was no documentation of the reason or indication for this as needed medication. Clinical Record 3: The 10/26/22 Hospice POC included the medications, "Amlodipine 2.5-10mg 1 tablet daily by mouth as needed and Tylenol 325 mg by mouth every 6 hours as needed." There was no documentation of the reason or indication for these as needed medications. Clinical Record 4: The 03/10/2023 Hospice plan of care included the medication, "Diazepam 5mg by mouth twice daily as needed" with no documentation of the reason or indication for this as needed medication. The POC included the medication, "Dulcolax 10mg 1 suppository per rectum" but did not include documentation of the frequency of administration. Clinical Record 5: The 01/23/2023 updated Hospice plan of care stated, "Sacral wound cleanse with wound cleanser, pat dry, apply Medi honey to wound bed and cover with foam dressing." The POC did not include documentation of the wound care frequency. Clinical Record 8: The updated Hospice pan of care dated 03/28/2023 stated, "Cleanse wound with wound cleanser, pat dry, cover with Telfa, 4X4 and tape." The POC did not include documentation of the wound location or the wound care frequency. Clinical Record 9: The 03/28/2023 Hospice plan of care stated, "Clean coccyx wound with wound cleanser, pat dry, apply skin prep and Medi honey, cover with foam dressing." The POC did not include documentation of the wound care frequency. Clinical Record 14: The 02/10/2023 Hospice POC did not include Oxygen at 2LPM via nasal cannula which was documented on the medication profile and on the 02/10/2023 nursing comprehensive assessment. The 02/10/2023 Hospice POC included the medications, "Diclofenac gel 1 Application every 4 hours as needed, Pepcid 20mg daily as needed, Nitroglycerin SL .4mg 1 tablet every 5 minutes x3 as needed, and Dulcolax 1200mg/30cc 15cc twice daily as needed." The POC did not include documentation of the reason or indication for these as needed medications. During an interview on 04/13/2023, the Administrator reviewed the associated care plans and agreed treatment and medication orders were incomplete and have since been corrected.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The organization develops a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed of discharged patients receiving bereavement services, revealed the agency did not ensure that a bereavement plan of care included the types of bereavement services to be offered and the frequency of service delivery. Clinical Record 13: The patient expired on 03/24/2023. The 03/23/2023 interdisciplinary team meeting documentation stated post death care was discussed during the meeting. As of 4/13/2023, the clinical record did not include written evidence of a bereavement plan of care which included the types and frequency of bereavement services to be provided. During an interview on 04/13/2023, the Administrator reviewed the associated clinical record and stated creation of the bereavement care plan had since been completed and added to patient record.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 8 of 13 (62%) clinical records reviewed of patients receiving aide services, revealed the agency did not ensure that the aide care plan included written instructions related to the aide frequencies for assigned tasks. Clinical Record 1: Patient was admitted to hospice services on 1/3/2023. The 01/23/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 2: Patient was admitted to hospice services on 10/14/2021. The 10/14/2021 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 3: The patient was admitted to hospice services on 10/26/2022. The 10/26/2022 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 4: The patient was admitted to hospice services on 3/10/2023. The 3/10/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 5: The patient was admitted to hospice services on 1/10/2023. The 01/10/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 6: The patient was admitted to hospice services on 2/27/2023. The 02/27/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 7: The patient was admitted to hospice services on 1/06/2023. The 01/06/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. Clinical Record 9: The patient was admitted to hospice services on 3/28/2023. The 3/28/2023 hospice aide care plan did not include documentation of a frequency for each assigned task. During an interview 04/13/2023, the Administrator reviewed the associated care plans and stated task frequencies had since been included where applicable.

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 clinical record review and interview. 1 of 13 (8%) clinical records reviewed of patients receiving aide services, revealed the agency did not ensure the aide provided services at the frequency ordered by the Interdisciplinary Group. Clinical Record 13: The 02/17/2023 Hospice aide care plan included orders for a sponge bath with an assigned frequency of 2x week. The aide documented completion of this task 3x week for the weeks of 03/13/2023 (documented as completed on aide visit notes dated 03/13/3023, 03/14/2023, 03/16/2023) and the week of 03/20/2023 (documented as completed on aide visit notes dated 03/20/2023, 03/21/2023, 03/23/2023). During an interview on 04/13/2023, the Administrator reviewed the associated record and stated additional care had been completed and the aide care plan should have been adjusted at that time.

If the hospice refers specimens for laboratory testing to a reference laboratory, the reference laboratory is currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements. This standard was not met as evidenced by interview. The agency did not ensure that the reference laboratory used for testing was appropriately certified. The hospice refers specimens for laboratory testing to a local reference laboratory. The agency did not have documented evidence that the reference laboratory was currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements. During an interview on 04/13/2023, the Administrator stated the agency had since obtained CLIA forms from the reference laboratories and would obtain from any additional partners as required. The hospice refers specimens for laboratory testing to a local reference laboratory, however, did not ensure the reference laboratory was currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements.