Village Care Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025. The initial plan of care dated 07/30/2025 included orders for once-a-month visits by both the Social Worker and Chaplain. The initial comprehensive assessment did not include documentation of a psychosocial assessment and a spiritual assessment. There was no documented evidence that the Social Worker and Chaplain completed the assessments as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/07/2025. The initial plan of care dated 04/07/2025 included an order for Social Worker visits once a month. The initial comprehensive assessment did not include documentation of a psychosocial assessment and there was no documented evidence that the Social Worker completed the assessment as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 09/17/2025. The initial plan of care dated 09/17/2025 included an order for once a month visit by the Social Worker. The initial comprehensive assessment did not include documentation of a psychosocial assessment completed within five calendar days of the patient’s election of benefit. The initial psychosocial assessment was dated 10/03/2025. The clinical record did not include documentation to explain the delay in completing the assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/08/2025. The initial plan of care dated 05/08/2025 included an order for once a month visit by the Chaplain. The initial comprehensive assessment did not include documentation of a spiritual assessment and there was no documented evidence that the Chaplain completed the assessment as part of the initial comprehensive assessment within five calendar days. The clinical record lacked documentation that provided a rationale or justification for the missed assessment. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the Social Worker and Chaplain assessments were not completed as ordered in the initial plan of care. The Administrator acknowledged awareness of the issue and reported that a performance improvement plan is currently in place to address and correct the deficiency.”

“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, herbal remedies, 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, drug therapy associated with laboratory monitoring. 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 observation and interview. In 1 of 14 (7%) home visit observations, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1: The patient elected the hospice benefit on 08/17/2023 with a primary diagnosis of Senile Degeneration of the Brain. During the home visit observation with the Home Health Aide (HHA) (Personnel Record 3), a medication review was completed by comparing the hospice medication profile to the patient’s current home medications. Review of medications was completed with the patient’s paid caregiver. The patient’s current home medications included Rytary 23.75 mg three times daily and Rytary ER 36.25 mg four times daily. Rytary and Rytary ER were not listed on the patient’s current hospice medication drug profile and were not included in the medication review process. The caregiver, who has provided care for the past year, stated the patient has been on these medications throughout her time with the patient. Following a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that a long-term medication currently taken by the patient was not documented on the agency’s drug profile.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/17/2023. Clinical record review revealed the comprehensive assessment did not include an initial bereavement assessment. There was no documented evidence of an initial bereavement assessment that included an assessment of the needs of the patient’s family. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/29/2024. Clinical record review revealed the comprehensive assessment did not include an initial bereavement assessment. There was no documented evidence of an initial bereavement assessment that included an assessment of the needs of the patient’s family. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the initial bereavement assessments were not completed at admission.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients followed the individualized plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/07/2025. Review of the clinical record revealed that the initial plan of care, dated 04/07/2025, included an order for Medical Social Worker (MSW) visits once per month. The order was also carried forward on the two most recent recertification plans of care. However, as of the date of record review on 11/05/2025, the MSW had not documented that social service visits had been provided to the patient. There was no documentation in the clinical record that the patient had declined social service visits. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025. Review of the clinical record revealed that the initial plan of care, dated 07/30/2025, included orders for Medical Social Worker (MSW) and Chaplain visits once per month. These orders were also carried forward on the most recent recertification plan of care. However, as of the date of record review on 11/05/2025, the Social Worker and the Chaplain had not documented that visits were provided to the patient. There was no documentation in the clinical record that the patient had declined MSW or Chaplain services. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed that the frequency of services documented in both the initial and recertification plans of care was inaccurate. Additionally, there was no supporting documentation indicating that the patient or caregiver declined the ordered services. The Administrator stated that this issue had already been identified internally and that a new Performance Improvement Plan (PIP) has been implemented to address it.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who died while on hospice services, the agency did not ensure the bereavement plan of care was developed. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/18/2024 and subsequently passed away while receiving hospice services on 06/20/2024. A review of the clinical record revealed that although both pre- and post-bereavement assessments were completed and bereavement mailings were sent within the required timeframes, there was no documented bereavement plan of care outlining the specific bereavement services to be provided to the bereaved parties. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/10/2024 and subsequently passed away while receiving hospice services on 02/25/2024. A review of the clinical record revealed that although both pre- and post-bereavement assessments were completed and bereavement mailings were sent within the required timeframes, there was no documented bereavement plan of care outlining the specific bereavement services to be provided to the bereaved parties. During interviews with the Administrator and the Alternate Administrator confirmed that the Bereavement Coordinator was actively following up with bereaved individuals. However, they acknowledged that the Bereavement Coordinator was not developing individualized bereavement plans of care following the death of the hospice patients.”

“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, 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 12 (8%) clinical records reviewed with hospice aide service provided, the agency did not ensure the Registered Nurse completed a hospice aide supervisory visit no less frequently than every 14 days. CLINICAL RECORD 11: The patient elected the hospice benefit on 06/13/2024. Hospice aide services were ordered at a frequency of two times per week beginning on 06/13/2024. The patient was discharged on 07/18/2024. There was no documented evidence in the clinical record that an aide supervisory visit was completed by the Registered Nurse, a total of 34 days and 20 days outstanding. During a joint record review and interview on 11/06/2025, the Administrator and the Alternate Administrator confirmed the record did not include documentation of a hospice aide supervisory visit that was completed during the patient’s episode of care. They both acknowledged the oversight and agreed that the required supervisory visit had not been conducted.”