Vantage Hospice

“It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.”

“It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.”

“It is required that the individualized plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, measurable goals and outcomes. In 1 of 23 clinical records reviewed revealed the agency did not ensure the plan of care included all the required elements. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the interventions for the foley catheter care or measurable outcomes for the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical record review of patients that elected hospice services revealed the agency did not ensure that a registered nurse made an on-site visit to the patient’s home to supervise the hospice aide was made no less frequently than every 14 days. CLINICAL RECORD 17: The clinical record review lacked evidence of and aide supervisory visit every 14 days in the benefit period 08/12/2025 to 10/10/2025. An aide supervisory visit was done on 08/14/2025 then 08/29/2025 (15 days). During a joint review of the clinical record with the Director of Nurses (Personnel Record 8) and the Administrator (Personnel Record 7) on 08/29/2025, they stated that the visit was changed due to the patient’s request. Also, stated that they are looking at updating the process so that this does not happen in the future.”

“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 the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed revealed the agency did not ensure to update the plan of care with changes in the comprehensive assessment. CLINICAL RECORD 5: The patient’s election of benefit (EOB) was 01/27/2025 with a diagnosis of Alzheimer’s Disease. On 08/19/2025, the nurse documented that the daughter was concerned about the patient’s possible skin cancer. On 08/27/2025, the nurse documented that the patient had undergone a skin biopsy to the scalp 3 days prior, however, the plan of care was not updated with changes. CLINICAL RECORD 8: The patient’s election of benefit (EOB) was 03/17/2025 with a diagnosis of Unspecified severe protein-calorie malnutrition. The initial comprehensive assessment dated 03/17/2025 stated that the patient has a 16 French Foley catheter. The plan of care dated 03/17/2025-06/14/2025 did not include the foley catheter. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated they do not know why the plan of care was not updated, but they would provide additional education to all staff.”

“It is required that the hospice designates a member of each Interdisciplinary Group who is responsible for a patient/resident in a SNF/NF or ICF/IID. The designated IDG member provides overall coordination of care of the patient/resident, working with the facility representative staff. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical record review of patients in a facility revealed that the agency did not ensure there was coordination of care with the facility staff. CLINICAL RECORD 3: The patient’s election of the hospice benefit (EOB) was dated 06/04/2025 with a diagnosis of Alzheimer’s Disease. The patient resided in a skilled nursing facility (SNF). There was no documented evidence as to the delineation of which agency (hospice or SNF) was to provide the wound care. There was a coordination of care form, however the wound care orders were not included and who was to perform the wound care was missing. During a joint review of the clinical record with the Administrator (Personnel Record 7) and Director of Nurses (Personnel Record 8) on 08/28/2025, they stated that coordination of care is not present in the clinical record. They are aware of coordination with the hospice staff. They will be providing additional education to the clinical staff on documenting coordination with the facility.”