Every finding on record at Wvuhs Home Care, LLC

Observed in Record Review. In 1 of 4 patient records reviewed, the Hospice did not adequately describe the severity of symptoms. Per the assessment, Hosp RR#1 NHV had a lesion/wound on her forehead. Although the RN took a picture of the wound, there was no further description of the wound in terms of size and or drainage. This was not consistent with the policy titled- Wound Assessment and was discussed with the director.

Observed in Record Review. In 1 of 1 patient records reviewed, that was on oxygen, did not have accurate orders. Hospice patient, Hosp RR#2 NHV was on oxygen and the orders reflected -to affected nostril. This observation was discussed with the director.

Observed in Record Review. In 11 of 19 patient records reviewed, the organization failed to assess patient needs as required. During record review for HOSRRHV#3, HOSRRHV#4, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10, the Hospice Nurse Surveyor observed the comprehensive psycho-social assessment was not completed per regulation. In HOSRRHV#3, HOSRRHV#4, HOSRRNHV#1, HOSRRNHV#6, HOSRRNHV#7, and HOSRRNHV#10, the comprehensive psycho-social assessment was not documented or performed. In HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#5, HOSRRNHV#7, and HOSRRNHV#9, a phone call was made for the assessment but the complete assessment was not completed as it was done on the phone. The family/ CG were not given the opportunity for an in home visit. For example due to the assessment being on the phone the environment and family portions of the assessment were left blank. Upon conversation with the Clinical Manager, she noted that the SW was PRN and that she primarily makes phone calls. Due to her schedule she was unable to make the comprehensive assessment visits in the home. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 4 of 19 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for HOSRRHV#3, HOSRRHV#4, HOSRRNHV#5, and HOSRRNHV#6, the Hospice Nurse Surveyor observed the bereavement assessment was not completed. For example in HOSRRHV#3, the patient was admitted 2 1/2 months prior to survey and the bereavement assessment had not been completed. In HOSRRHV#4, HOSRRNHV#5, and HOSRRNHV#6, the patients did not have documentation of a bereavement assessment. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization failed to assess and reassess its patients. During record review for all records, the Hospice Nurse Surveyor observed not all assessments and reassessments were completed as required. Upon discussion with the Clinical Manager, it was noted that the organization was not currently assessing for volunteer needs. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 2 of 19 patient records reviewed, the organization failed to plan the patients' care. During record review for HOSRRHV#3, the Hospice Nurse Surveyor observed the plan of care was not updated to reflect current needs. For example in HOSRRHV#3, the patient had a goal anticipatory grief, goal to be achieved in 3 visits and dyspnea at end of life to be achieved within two weeks. The patient had been on service for 1 year and it had not been updated. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the goals were not individualized. For example in both HOSRRHV#1, the patient had a goal of the patient/ caregiver will verbalize and demonstrate ability to manage the patients anxiety with a goal timeframe of throughout care The goal timeframe was not individualized. The patient had a SW goal of will explore reactions to and verbalize acceptance of impending loss with no timeframe and it had been in place since SOC. The patient also had a SC goal of assess for signs and symptoms of spiritual distress which was entered at SOC but the Chaplain had no frequency orders and had not updated the goal. In HOSRRHV#4 the patient had a goal of Pt/CG distress heard acknowledged and reduced with no timeframe. In HOSRRNHV#3 the patient had a goal related to anticipatory grief with no timeframe to achieve that goal. In HOSRRHV#1, the patient had issues with bladder incontinence and was following up with a urologist. She mentioned to surveyor that it was very frustrating and preventing her from going to dinner with her family. But this was not addressed on the Plan of Care. SW and SC had no goals on the plan of care. In HOSRRHV#2, the patient had a goal for dyspnea at the end of life but the patient was not actively dying. The patient was also on hospice for protein calorie malnutrition but nutrition was not addressed on her plan of care. The patient also had issues with constipation but it was not addressed on the plan of care. In HOSRRNHV#1 and HOSRRNHV#3, the Spiritual Counselor was making visits but had no active goals or interventions on the plan of care related to the grief support his notes stated he was providing. In HOSRRNHV#3- the patient was actively dying and receiving daily visit for dyspnea, anxiety and comfort measures but these her not addressed on the plan of care. Also the patient had two days in GIP but this was no added to the plan of care. In HOSRRNHV#4, notes stated that the patient was having active vaginal and rectal bleeding but that the family insisted on the patient continuing to take her Eliquis. Upon conversation with the supervisor, she stated that the daughter was a nurse and that the Hospice Clinician is continuing to educate on this medication and the precautions related to the current bleeding concerns. But this was not addressed on the plan of care. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 7 of 19 patient records reviewed, the organization failed to provide care, treatment, or services in accordance with orders. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#7, HOSRRNHV#8, orders were not obtained or followed. For example in HOSRRHV#1, the Spiritual Care Coordinator made a visit but did not have orders to do so. Upon conversation with the Clinical Manager she stated he usually calls us to add the orders for a visit when he needs it. There were no frequency orders on the Plan of Care for Spiritual Care.In HOSRRHV#2, HOSRRHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#7, HOSRRNHV#8, did not have orders for frequency of Chaplain visits on the Plan of Care but the Chaplain had been visiting. This was discussed and reviewed with the Clinical Manager.

Observed in Record Review. In 10 of 19 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRHV#4, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10, the Hospice Nurse Surveyor observed the interventions were not individualized. For example in both HOSRRHV#1, the patient had issues with bladder incontinence and was following up with a urologist. She mentioned to surveyor that it was very frustrating and preventing her from going to dinner with her family. But this was not addressed on the Plan of Care. SW and SC both have goals on the Plan of Care with no goal timeframes and no current frequency orders. In HOSRRHV#2, the patient had a goal for dyspnea at the end of life but the patient was not actively dying. The patient was also on hospice for protein calorie malnutrition but nutrition was not addressed on her plan of care. The patient also had issues with constipation but it was not addressed on the plan of care. In HOSRRNHV#1 and HOSRRNHV#3, the Spiritual Counselor was making visits but had no active goals or interventions on the plan of care related to the grief support his notes stated he was providing. In HOSRRNHV#3- the patient was actively dying and receiving daily visit for dyspnea, anxiety and comfort measures but these her not addressed on the plan of care. Also the patient had two days in GIP but this was no added to the plan of care. In HOSRRNHV#4, notes stated that the patient was having active vaginal and rectal bleeding but that the family insisted on the patient continuing to take her Eliquis. Upon conversation with the supervisor, she stated that the daughter was a nurse and that the Hospice Clinician is continuing to educate on this medication and the precautions related to the current bleeding concerns. But this was not addressed on the plan of care. In HOSRRHV#2, HOSRRHV#3,HOSRRHV#4, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10, the patient's had orders for oxygen to the affected nostril, without clarification of per nasal cannula as the Manager stated it should be. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for HOSRRHV#2, the Hospice Nurse Surveyor observed lack of documentation of collaboration in order to coordinate efforts to support patient goals. During surveyor visit with the LPN, the caregiver stated that they were told by Brenda RN Case Manager to hold the Humira which was due the week prior due to the patient's cold symptoms. There was no documentation in the EMR that this occurred, and no documentation that the provider was aware. The LPN then placed an order to hold the medication based on what the caregiver stated without collaborating with Brenda RN Case Manager or the provider. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Tracer Activities. The organization failed to comply and analyze data. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization had been collecting infection data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to implement activities for prevention and control of infections and communicable disease. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization was not currently collecting infection data as evidenced by unable to provide the documentation at the time of survey. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to document improvement in hand hygiene. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization had been collecting hand hygiene visit date but the data was not aggregated or analyzed to show compliance. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HOSRRBR#2, the Hospice Nurse Surveyor observed the patient was on service for a month and had passed away. The post death bereavement risk assessment was completed 7 months post death, even though the bereavement care plan was being followed. Per organizational policy Bereavement Services: the initial post death assessment was to be done at the initial phone call or funeral home visit with a second phone call for a second update to the post death bereavement assessment to take place 4-6 weeks post death. These timeframes were not adhered to. This was discussed and reviewed with the Hospice Clinical Manager. Observed in Record Review. In 10 of 19 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#5, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10, the Hospice Nurse Surveyor observed not all assessments and reassessments were completed as required. For example in all records listed above, the patients did not have a comprehensive spiritual care assessment completed. There was no documentation to state why these were not completed. The Chaplain/ Spiritual Counselor was only a part time employee upon conversation with him, he was getting to the visits when he was scheduled to work. There was no other Spiritual Counselor coverage. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, where aide services are ordered, the organization failed to document a plan of care to include all services needed. During record review for HOSRRHV#1, HOSRRHV#2, and HOSRRHV#3, the Hospice Nurse Surveyor observed not all items were included on the Plan of Care. For example in HOSRRHV#1, HOSRRHV#2 and HOSHV#3, HOSRRNHV#4, all patients were a fall risk and had oxygen but were not addressed on the plan of care. The oxygen was listed but directions for whether they could remove it for bathing was not included. In HOSRRNHV#2, the patient was a fall risk but it was not addressed on the aide plan of care. In HOSRRNHV#5, the patient had SN precautions for aspiration, bleeding and oxygen but it was not addressed on the aide plan of care. In HOSRRNHV#6, the patient was a fall risk but it was not addressed on the aide plan of care. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed, volunteer files, the organization failed to provide orientation to staff. During Human Resources tracer activities, the Hospice Nurse Surveyor observed the Volunteer HR file did not contain documentation of orientation. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to provide all services to meet the patient needs. During tracer activities for the Volunteer Program, the Hospice Nurse Surveyor observed the organization had been operating for 3 years and per the Clinical Manager had never met the 5% of total patient care hours. The organization had one volunteer in place for 2024 and that one volunteer did just one visit equaling 1 hour of care. The organization was beginning the on-boarding process for a new Volunteer Coordinator during survey. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to implement policies and procedures that guide and support patient care, treatment, or services as evidenced by non-compliance with policy and procedure implementation at COP 418.54 and 418.56. This was discussed and reviewed with the Hospice Leadership Team. Observed in Tracer Activities. The organization failed to provide for its planned scope and level of care, treatment, or services. During tracer activities for Leadership and during record reviews, the Hospice Nurse Surveyor observed the organization was not currently able to meet the needs of their patients as evidenced by no psycho-social visits being completed, intermittent spiritual counseling visits being completed and no regular/ planned visits from either the SW or SC providers. The Spiritual Counselor was a part employee, working only 20 hours a week. 7/10 comprehensive assessments were not completed with no documentation as to the patient refusing the visits. The Spiritual Counselor did make visits after the patient came onto care but there was no visit frequency. He was adding orders as he was able to see the patient depending on his calendar. The SW was PRN with the Hospice Organization and worked full time for the hospital associated with the Hospice organization. She performed phone calls only. There was no documentation of an attempt to offer in person visits and 10/10 psycho-social comprehensive assessments were performed on the phone and not completed due to the limitations of the phone visit. For example she was unable to assess the environment and the family relations. The Hospice Surveyor also attempted to schedule a phone meeting with the SW/ Bereavement Coordinator to discuss the bereavement program but due to her schedule that was not able to happen during the five day survey. Upon conversation with the Hospice Leadership Team, it was noted that they have struggled to keep positions due to low average daily census even though their unduplicated numbers was high. They have also struggled to keep employees in these roles. The Hospice AVD is 15 with an unduplicated of 195. The Hospice Admin/ Clinical Manager is in charge of both Home Care and Hospice. She also makes home visits, take's after hours call and is currently the Volunteer Coordinator. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to maintain a record that reflected the care, treatment, or services. During record review for HOSRRBR#1, the Hospice Nurse Surveyor observed the patient had passed away a month prior to survey and the death visit note did not contain all required elements per policy. The death note only contained time of death. It did not include documentation of the patient details such as absence of pulse and respirations. It also did not include information about post mortem care. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 1 of 6 patient records reviewed, the hospice POC had not been updated with all of the services needed. In the chart for HSRR#1, the Volunteer Spiritual services were added, however there was no frequency of services included on the Hospice POC as confirmed with the Administrator and Volunteer Coordinator.

Observed in Record Review. In 2 of 6 patient records reviewed, the hospice plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HSHV#2, the patient's fluticasone order was missing the frequency of administration as confirmed with the RN at the visit. In the chart for HSHV#3, the patient was at risk for pressure ulcer development and falls, yet the plan of care did not include any interventions nor goals related to these potential problems. The Skilled Nursing facility plan of care did contain these interventions and goals, however, which had been jointly collaborated on to facilitate the coordinated plan of care between the SNF and hospice. This was discussed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During HSHV#2 and HSHV#3, the RN cleaned his stethoscope, pulse ox and BP cuff with PDI wipes per organizational policy, however, did not follow the required 3 minute wet time per organizational policy and manufacturer's recommendations as discussed with the RN and the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the RN had not prepared complete patient care instructions for the hospice aide. In the chart for HSRR#1, the aide care plan included both a shower and bed bath in the assignment. This was confirmed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the aide had not provided services ordered in the hospice plan of care. In the chart for HSHV#3, the aide was routinely taking vital signs. This was not assigned on the aide interventions to be provided. This was discussed with the chart review nurse assisting with the survey.

Observed in Record Review. In 3 of 6 patient records reviewed, the patient record did not contain accurate information. In the chart for HSHV#2, the Plan of Care included an order for PT evaluation. As confirmed with the RN, this was an error in documentation and the patient did not actually have an order for a PT evaluation. In the chart for HSRR#2, the initial SN assessment stated that oxygen was not stored properly, also that patient was not informed of oxygen risk findings. Upon discussion with the RN who made the visit, this was incorrect information as discussed with the Administrator. In the chart for HSRR#3, the wound care provided was incomplete and did not include the cleansing agent. This was discussed with the Administrator.