Venarks Hospice Inc.

“Upon patient record review 3 of 14 (Patient #1,#5,#13) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: There was no evidence of a psychosocial assessment completed within 5 days. The first documented psychosocial assessment was 02-24-25. Patient #5: The patient was admitted on 07-01-25 and there was no spiritual assessment completed until 07-08-25 which is greater than 5 days. Patient #13: There was no evidence of a psychosocial assessment within 5 days of the admission.”

“Upon patient record review 7 of 14 (Patient #1,#3,#5,#6,#7,#8,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: MiraLAX 17gm per scoop was listed on the medication profile without evidence of a diluent. Patient #3: Melatonin by mouth was on the medication profile but written as “0” times a day. Additionally, Mupirocin and Zinc Oxide were on the medication profile, but without evidence of a route of application. Patient #5: Tizanidine and Polyethylene glycol were listed on the medication profile as PRN, but there were no reasons for the PRN listed. Patient #6: An order for O2 2-5 L via NC was on the initial plan of care, but there was no evidence it was added to the medication profile. Patient #7: Zinc oxide was on the medication profile without a route of application. Additionally, the initial plan of care indicated oxygen was ordered, but there was no evidence it was listed on the medication profile. Patient #8: Zinc oxide was listed on the plan of care without evidence of a route. Additionally, an order for oxygen 2-5 L per NC was on the initial plan of care, without evidence of it being listed on the medication profile. Patient #10: Oxygen was ordered on the initial plan of care, but there was no evidence it was added to the medication profile.”

“Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5: There was no evidence of a bereavement assessment completed until 07-08-25 which is greater than 5 days after the admission date of 07-01-25.”

“Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10: On 08-14-25 there were orders for the SN to visit 1 x week for wound care, and the family to provide wound care on the other days. The SN visited on 08-18-25, but there as no evidence of a wound care assessment.”

“Upon patient record review, 4 of 14 (Patient #1,#8,#9,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient’s terminal illness was heart failure, but there was no evidence of a care plan for Cardiac related goals or interventions. Patient #8: The patient’s terminal illness was Senile Degeneration, but there was no evidence of goals or interventions related to Neuro on the care plan. Patient #9: The patient’s terminal diagnosis was Heart failure, but there was no evidence of cardiac related goals or interventions listed on the care plan. Patient #10: The patient’s terminal diagnosis was Alzheimer’s, but there was no evidence of Neuro related goals or interventions listed on the care plan.”

“Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #5: The plan of care dated 08-18-25 included interventions to assess edema and grade, encourage elevation and instruct in use of diuretics. However, there were no diuretics ordered or listed on the medication profile and there was no location of edema identified on the plan of care or throughout the assessments.”

“Upon patient record review, 2 of 14 (Patient #6,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6:The aide plan of care frequency for the aide indicated 5 days a week and 1 PRN visit every 7 days. Patient #10: The aide plan of care frequency for the aide indicated 5 days a week and 1 PRN visit every 7 days.”

“Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: Aide visit note was signed and documented as a visit on 03-02-25 which was after the date of death of the patient. The comments section on the note indicated the visit was from 02-03-25 and the date had been transposed.”