Every finding on record at Wings Over Virginia LLC

Based on record review, interview, and policy review, it was determined that the agency failed to ensure the initial "Spiritual Counselor Comprehensive Assessment" and "Medical Social Services Comprehensive Assessment" were completed withing five calendar days after the start of hospice services for nine patients (P3, P4, P5, P7, P8, P10, P12, and P14) of 14 current patients reviewed for spiritual assessments and social services assessments. This failure had the potential to cause the patient's desired wishes not to be honored.Findings included: --- There was no documented evidence that the hospice agency completed the initial Chaplain assessment and the Social Services assessment within five days after the start of hospice services for nine patients P3, P4, P5, P7, P8, P19, P12, and P14. In addition, there was no evidence that the hospice had a system in place to ensure that these assessments were completed timely. Cross Reference: L523.

Based on interview, record review, and policy review, the agency failed to ensure that the "Spiritual Counseling Comprehensive Assessment" and/or the "Medical Social Services Comprehensive Assessment" was completed within five days of the election of hospice benefits for 9 of 14 sampled patients (P3, P4, P5, P7, P8, P10, P11, P12, and P14). This had the potential to cause patient and/or caregiver needs to be unidentified and unmet.Findings included: --- Review of the agency's policy titled, "Plan of Care Process," dated 09/01/24, revealed, ". . . A comprehensive assessment will be completed by the IDG/IDT [interdisciplinary group/team] no later than five calendar days after the election of hospice care in consultation with the attending physician (if any) . . . The contents of the comprehensive assessment will identify patient demographic information, along with the physical, psychosocial, emotional and spiritual needs related to the terminal illness that will be addressed to promote the Hospice patient's well-being, comfort, and dignity throughout the dying process . . ."1. Review of P3's electronic medical record (EMR) revealed P3 had a Start of Care (SOC) date of 07/02/24 with a terminal diagnosis of Huntington's Chorea (a neurological disorder). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Medical Social Services" comprehensive assessment was complete within the first five days of the SOC.2. Review of P4's EMR revealed P4 had a SOC date of 04/21/25 with a terminal diagnosis of Parkinson's disease (a neurological disorder). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Medical Social Services" comprehensive assessment was completed within the first five days of the SOC.3. Review of P5's EMR revealed P5 had a SOC date of 10/18/23 with a terminal diagnosis of CVA (cerebral vascular accident-stroke). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" and "Medical Social Services" comprehensive assessments were completed within the first five days of the SOC. 4. Review of P7's EMR revealed P7 had a SOC date of 03/20/25 with a terminal diagnosis of alcoholic cirrhosis of the liver. Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" comprehensive assessment was completed within five days of the SOC.5. Review of P8's EMR revealed P8 had a SOC date of 04/25/25 with a terminal diagnosis of end-stage renal disease (ESRD). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" and "Medical Social Services" comprehensive assessments were completed within the first five days of the SOC.6. Review of P9's EMR revealed P9 had a SOC date of 05/13/25 with a terminal diagnosis of Alzheimer's disease. Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" comprehensive assessment was completed within the first five days of the SOC.7. Review of P10's EMR revealed P10 had a SOC date of 05/22/25 with a terminal diagnosis of congestive heart failure (CHF). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" comprehensive assessment was completed within the first five days of the SOC.8. Review of P11's EMR revealed P11 had a SOC date of 04/30/25 with a terminal diagnosis of leukemia (a type of cancer). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" comprehensive assessment was completed within the first five days of the SOC.9. Review of P14's EMR revealed P14 had a "SOC" date of 12/08/23 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). Review of the "Visit Management" tab in the EMR revealed no documentation that the "Spiritual Counseling" and the "Medical Social Services" comprehensive assessments were completed within the first five days of the SOC.During an interview on 07/08/25 at 10:30 AM, Chaplain1 was asked when the comprehensive assessment was to be completed after a patient was admitted into hospice. Chaplain1 stated, "Within five days." Chaplain1 was asked why the "Spiritual Counseling" assessment has not been completed consistently. He stated, "Well, sometimes I make a phone call, and they don't want services, but I see what you are saying."During an interview on 07/09/25 at 11:15 AM, the Social Worker was asked what the timeframe was for completing a "Medical Social Services" comprehensive assessment when a patient is admitted into hospice care. The Social Worker stated, "five days."During an interview on 07/09/25 at 2:00 PM, the Administrator acknowledged that the comprehensive assessments had not been consistently completed.

Based on interview, record review, and policy review, the agency failed to ensure the care plan was developed or revised for five of 14 (Patients (P)1, P2, P3, P4, and P14) current sampled patients out of total sample of 19. This deficient practice had the potential to affect the patients' quality of life and cause unmet care needs.Findings included: --- Review of the agency's policy titled, "Plan of Care Process," dated 09/01/24, revealed, ". . . To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs . . . The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions . . ."1. Review of P1's electronic medical record (EMR) revealed a Start of Care (SOC) date of 06/30/25 with a terminal illness of amyotrophic lateral sclerosis (ALS-a neurological disease). Review of the "Plan of Care" revealed the care plan did not contain a focus/problem for the terminal diagnosis of ALS, the patient/family goals for care, or specific interventions related to the terminal diagnosis of ALS.2. Review of P2's EMR revealed a SOC date of 05/01/25 with a terminal diagnosis of malnutrition. Review of P2's "Orders" revealed P2 had accepted "Medical Social Services" on 06/01/25. Review of the "Plan of Care" revealed the care plan did not contain a focus/problem, the patient/family goals, or specific interventions related to "Medical Social Services."3. Review of P3's EMR revealed a SOC date of 07/02/24 with a terminal diagnosis of Huntington's chorea (a neurological disease). Review of P3's "Orders" revealed P3 had an order, dated 04/22/25, for a "Cervical collar-to be worn while patient is sitting upright position in wheelchair; purpose to minimize the impact of involuntary movements due to chorea. Review of the "Plan of Care" revealed the care plan was not updated to include the cervical collar.4. Review of P4's EMR revealed a SOC date of 04/21/25 with a terminal diagnosis of Parkison's disease (a neurological disorder). Review of P4's "Orders" revealed P4 had increased pain which resulted in an increase of P4's pain medication. Review of the "Plan of Care" did not show that P4's "Pain Care Plan" was updated to include the addition of Fentanyl patches and Methadone (pain medications).5. Review of P14's EMR revealed a SOC date of 12/08/23 with a terminal diagnosis of COPD. During a home visit on 07/08/25 at 11:00 AM with Social Worker (SW)1, SW1 and P14 had a discussion related to getting P14 care and services from the Veterans Administration (VA). Review of P14's "Plan of Care" did not evidence that a "Medical Social Services Care Plan" had been developed despite having "Medical Social Service" visits.During an interview on 07/09/25 at 2:00 PM, the Administrator and the Nurse Practitioner acknowledged the lack of either a developed care plan or revisions to the care plan, as necessary.

Based on personnel file review and staff interview, the agency failed to identify the date that a Tuberculosis (TB) QuantiFERON test was performed and ensure that a TB test was administered upon hire for two of six employee files reviewed (Registered Nurse (RN) 1 and (Certified Nurse Aide (CNA) 3. This failure had the potential for infectious diseases to be transferred to patients and other staff employed by the agency.Findings included: --- Review of the agency's policy titled, "Infection Control Program," 01/01/25, revealed, "To maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases."1. Review of RN1's personnel file revealed a hire date of 05/01/25. There was evidence of a QuantiFERON test having been performed; however, there is no date on the test to show when it was performed.2. Review of CNA3's personnel file revealed a hire date of 11/06/23. There was no evidence to show that CNA3 was administered the TB test upon hire.During an interview on 07/09/25 at 12:30 PM, the Nurse Practitioner (NP) confirmed that RN1's QuantiFERON test was not dated and that CNA3 was not administered the TB test upon hire.

Based on interviews, record reviews, and policy review, it was determined the agency failed to develop and implement a volunteer program and demonstrate recruitment and retention techniques specific to the location of the hospice agency. This failure had the potential to cause patients to have unmet needs.Findings included: --- During an interview on 07/09/25 at 11:30 AM, the Volunteer Coordinator stated she had only been at the Hospice agency for a "little over a month" and currently had no active volunteers.During an interview on 07/09/25 at 1:37 PM, Administrator 2 stated that she was considered a volunteer when her paid hours go over 20 hours in a week; however, there was no documentation to show that the facility had a cost savings of 5% of their patient roster.Cross-reference: L645: Recruitment and Retain.

Based on interviews, record review, and policy review, the hospice agency failed to fully develop and implement an effective volunteer recruitment effort. This had the potential to cause 105 of 105 residents to have unmet needs.Findings included --- Review of the agency's policy titled, "Volunteers," dated 09/01/24, revealed, ". . . The Hospice will provide volunteer services to be used in day-to-day administrative and/or direct patient care roles . . . The Hospice will maintain, document, and provide volunteer training and orientation that is consistent with hospice industry standards . . . The Hospice will document and demonstrate viable and ongoing efforts to recruit and retain volunteers . . ."On 07/09/25 at 11:00 AM, after the IDG [interdisciplinary group] meeting, the Administrator and the Nurse Practitioner was asked why the Volunteer Coordinator, who was in attendance at the meeting, was not asked if there was a volunteer with the patient or if they wanted a volunteer as it was not discussed during the meeting. The Nurse Practitioner stated, "We don't have any volunteers right now."During an interview on 07/09/25 at 11:30 AM, the Volunteer Coordinator (VC) was asked how long she had been in her position with the Hospice Agency. The VC stated, "A little over a month." The VC further stated, "I do have three or four volunteers signed up right now, but we are waiting for their background checks to be done."During an interview on 07/09/25 at 1:37 PM, Administrator 1, the NP, and Administrator 2, who was available by phone, were asked if the agency had brought the lack of volunteers to QAPI [quality assurance and performance improvement]/. Administrator 2 stated, "Yes, we started a PIP [performance improvement program] and it is still current. Since we were a start-up in 2022, we wore many hats, and we were still under the COVID waivers. We have been posting flyers, and we did hire a coordinator previously, but she did not produce any volunteers." Administrator 2 further stated, "We have had various volunteers on and off, but we struggle. Our Governing Board gave us the authorization for a full-time volunteer coordinator, and so we hired the VC."

Based on interview, record review, and review of agency policy, the agency failed to ensure hospice records were provided to a receiving hospice agency or to a provider for one of two patients (Patient (P)15) reviewed for discharge in a total sample of 19. This failure placed the patient at risk of unmet care needs. Findings included: --- Review of the agency's policy titled, "Coordination of Care," dated 09/01/24, revealed, "To ensure coordination of all care provided for patients receiving hospice services and/or services from other provider . . . All communications and coordination of care is documented in the clinical record . . ."Review of P15's electronic medical record (EMR) revealed a Start of Care (SOC) date of 01/24/24 with a terminal diagnosis of lung cancer.Review of the "Visit Management" tab in the EMR revealed that R15 had moved out of the hospice area to another state with his family. There was no further documentation to show that the hospice had identified who the receiving hospice was, or that the hospice had provided R15's discharge summary, plan of care, and physician's orders for continuity of care.During an interview on 07/08/25 at 1:59 PM, the Nurse Practitioner (NP) was asked if there was any information in the EMR to show the transfer to another hospice or primary care physician. The NP stated, "I looked through emails and everything, but there is nothing on coordination of care."

Based on record review, interview, and agency policy review, the agency failed to provide the attending physician with a copy of the hospice discharge summary, plan of care, and physician orders when one of two patients (Patient (P) 17) reviewed for discharge in a total sample of 19 revoked the hospice benefit due to no longer being terminally ill. This failure had the potential for a re-admission to the hospice agency.Findings included: --- Review of the agency's policy titled, "Coordination of Care," dated 09/01/24, revealed, "To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers . . . Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions."Review of P17's electronic medical record (EMR) revealed P17 had a Start of Care (SOC) date of 02/24/25 with a terminal illness of senile degeneration of the brain. The record further revealed that on 04/28/25, P17 revoked hospice services due to no longer being terminally ill.The EMR further revealed that there was no documented evidence that the attending physician was provided with a copy of the discharge summary, the plan of care, or the physician's orders for continuity of care.During an interview on 07/09/25 at 2:05 PM, the Nurse Practitioner (NP) confirmed that no information was shared with the receiving physician.

Based on interviews, record review, the agency failed to provide a signed "Hospice Election of Benefits form" and the hospice "Plan of Care" to a Skilled Nursing Facility (SNF) for one of three sampled patients (Patient (P)1) residing in a SNF out of a total sample of 19. Failure to provide this information had the potential to affect the care received within the SNF.Findings included: --- Review of P1's electronic medical record (EMR) revealed a Start of Care (SOC) date of 06/30/25 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS).During a SNF visit with Registered Nurse (RN)3 on 07/08/25 at 9:00 AM, RN3 stated, "He does not have his hospice book here yet, I believe they are bringing it over about 3:00 PM today." RN3 was asked why P1's hospice book had not been made available at the SNF in the last seven days. RN3 stated she did not know why.During an interview on 07/09/25 at 1:59 PM, the Nurse Practitioner (NP) acknowledged that P1's hospice book, including the "Election of Benefits" form, should have been at the SNF sooner.

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; Supplements; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy;The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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, interview and observation. 3 of 11 (27%) clinical records reviewed revealed the comprehensive assessment did not include all current drugs taken by the patient. Record #90045 was reviewed and identified the patient elected the hospice benefit on 12/13/2021. In reviewing medications during a home visit it was identified that Morphine 20mg/ml, which appears on the medication profile, was not in the patients home. Record #49230 was reviewed and identified the patient elected the hospice benefit on 1/14/2022. Amlodipine 10-20mg po q day was written at initial assessment but was not found on the medication profile. There was no documented evidence that a medicne review was completed for this medication. Record #52522 was reviewed and identified the patient elected the hospice benefit on 12/29/2021. An order was written on 12/30/2021 to discontinue all medications except Morphine and Ativan. The medication profile did not indicate the following medications were discontinued: Ultram Trazedone Vitamin B12, Senna S, Vitamin D3, KCl elixir, Aspirin, Furosemide, Citalopram, Montclukast, Omeprazole, Tizanide, Atorvastatin. The Director of Nurses was interviewed on 3/9/2022 and agreed that the medication profile was not updated on the identified records. She had no additional information to provide.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) clinical records reviewed was misssing evidence of docummentation of physician's orders. Record #99154 was reviewed and identified the patient elected the hospice benefit on 2/10/2022. The drug profile indicated that Hycet 7.5/325 was discontinued on 2/11/2022, The POC did not conntain a physician order to discontinue the medication. Record #49230 was reviewed and identified the patient elected the hospice benefit on 1/14/2022. The History & Physical and Initial Assessment identify that patient was taking Regular insulin at 25units subcutaneously every day. There was no documetned evidence in the POC to continue or discontinue this medication. Record #41300 was reviewed and identified the patient elected the hospice benefit on 2/4/2022. A wound was identified on a comprehensive assessment on 3/1/2022. The plan of care on 3/7/2022 stated "worsening wound. Necrotic crevasses of buttocks. Daily cleaning, Barrier cream applied." The record did not contain wound care orders . During an interveiw on 3/9/2022, the Director of Nurses agreed that orders were missing for the identified records. She had no additional information to provide.