Vc Hospice, Inc.

“It is required that the hospice policies and procedures address the minimum information provided to facilitate patient evacuation and transportation including If the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) the organization did not ensure that patient documented emergency plans included patient-specific information necessary to facilitate patient evacuation and transportation as required. During a concurrent review of clinical records and an interview with the organization’s Clinical Supervisor on 10/24/2025, it was revealed that Clinical Records 1-14 did not include evidence that each patient’s documented emergency plan included required information to facilitate patient evacuation and transportation including if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). Before the exit conference on 10/24/2025, the Clinical Supervisor provided updated Patient Emergency Plan documents for each of the seven active patients [Clinical Records 8-14] that included patient-specific information required to facilitate patient evacuation and transportation. The Clinical Supervisor stated, “We will deliver these updated patient emergency plans to each of our currently active patients, and going forward, we will include this information on all Patient Emergency Plans.” During a concurrent review of clinical records and an interview with the organization’s Clinical Supervisor on 10/24/2025, it was revealed that Clinical Records 1-14 did not include evidence that each patient’s documented emergency plan included required information to facilitate patient evacuation and transportation including if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). Before the exit conference on 10/24/2025, the Clinical Supervisor provided updated Patient Emergency Plan documents for each of the seven active patients [Clinical Records 8-14] that included patient-specific information required to facilitate patient evacuation and transportation. The Clinical Supervisor stated, “We will deliver these updated patient emergency plans to each of our currently active patients, and going forward, we will include this information on all Patient Emergency Plans.””

“It is required that the written Patient Bill of Rights includes the right to have a confidential record per state and federal law and regulation; Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 14 (100%) of clinical records reviewed, it was revealed that the Patient Bill of Rights distributed in writing to patients did not include the statement of notification that each patient has the right to have access to or release of patient information and clinical records as permitted in accordance with 45 CFR parts 160 and 164. DOCUMENT 1: During a concurrent review of clinical records and an interview with the organization’s Clinical Supervisor on 10/24/2025, it was revealed that Clinical Records 1-14 did not include evidence that patients had received written notification that each patient has the right to have access to or release of patient information and clinical records as permitted in accordance with 45 CFR parts 160 and 164. Policy titled Patient Rights with a revision date of May 2020 was provided and reviewed with the Clinical Supervisor and Office Manager who both confirmed that the Patient Rights policy and the Patient Bill of Rights in the patient handbook given to each patient at the initiation of services did not include the statement as follows: “Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164”. During the exit conference on 10/24/2025, the Administrator/DPCS stated that updated Policies and Procedures, which included required Patient Rights written notification, would be purchased and approved by the Governing Board as soon as possible.”

“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 and interview. In 1 of 1 (100%) of clinical records reviewed that included hospice aide personal care services, the organization did not ensure that the aide plan of care included all pertinent precautions and safety instructions. CLINICAL RECORD 11: The patient was admitted to hospice services on 05/05/2025 with primary and pertinent secondary diagnoses that included COPD and dependence on supplemental oxygen [2-5 liters per minute continuously per nasal cannula titrated for comfort]. The patient’s fourth benefit period plan of care effective 10/02/2025 through 11/30/25 included an order for weekly Aide personal care services and oxygen management and safety precautions. During a concurrent clinical record review and interview with the Clinical Supervisor on 10/24/2025, the Clinical Supervisor confirmed that the aide plan of care effective 10/05/2025 did not include special precautions or instructions related to the patient’s continuous use of supplemental oxygen as was included on the patient’s individualized plan of care effective 10/02/2025 through 11/30/2025.”