Sentara Home Care Services - Chesapeake

“Upon patient record review, 6 of 19 (Patient #2,3,4,6,9,14) 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: Patient 2: Upon home visit finding, the facility MAR contains Vit D2, Deep sea nasal spray, Flonase, Lidocaine, MiraLAX, Sodium Bicarbonate. These medications were not on the medication profile. Patient 3: The medication profile contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 4: Upon home visit finding, the patient is not taking Sertraline and has not taken it for over a year per the caregiver. This medication remains on the medication profile Patient 6: The medication profile contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 9: The medication profile contains an order for Depakote “take 1 tab by mouth Radiology and PVL freq” PVL and Freq are not approved abbreviations and is unclear. Patient 14: The medication profile contains Acetaminophen 325mg Q4 hours prn and Acetaminophen 500mg every 4 hours prn with no directive for maximum daily limit for acetaminophen.”

“Upon patient record review, 2 of 19 (Patient #7,11) 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 7: The agency policy “wound care at home” includes measuring a wound at each dressing change. The SN performed wound care on 4/14/26 and did not measure the wound. Patient 11: The current POC contains an order for site care to the biliary drains and JP drain for dressing changes weekly and prn if soiled. There is no evidence the JP or bilateral biliary drain sites were assessed during the visits or if the dressing change was completed by the SN or the family the weeks of 3/23/26, 3/24/26, 3/26/26. On 4/6/26 SN documented biliary drains flushed without resistance. There is no documentation regarding wound care to site or assessment of site. The last documentation regarding the JP drain was 3/26/26, the order for JP tube care remains active though there is not documentation since 3/26/26 of JP care being completed.”

“Upon patient record review, 2 of 19 (Patient #13,14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Patient 13: The week of 12/1/25-2/22/26 there is an order for SN 1 visit a week which overlaps the order for SN 1 visit every week for 13 weeks 2/23/26-5/23/26 in the same Medicare week, there was a visit made on 2/23/26. The orders were not written correctly for the Medicare weeks. Patient 14: The SN visit schedules are overlapping the first order string is 2/12/26-4/12/26 for 1 visit every week for 10 weeks and then starting 3/2/26-4/12/26 2 visits every week for 7 weeks and then 1 visit every week for 4 weeks starting 3/26/26-4/18/26 this is causing the EMR to make it look like visits are missed though the visits were made. The orders were not written correctly for the Medicare weeks.”

“Upon patient record review, 11 of 19 (Patient #1,2,3,4,6,9,10,11,12,14,15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The current POC contains a care plan for foley catheter. There are no orders for size, frequency of change. Patient 2: Upon home visit finding, the facility MAR contains Vit D2, Deep sea nasal spray, Flonase, Lidocaine, MiraLAX,Sodium Bicarbonate. These medications were not on the POC. Patient 3: The current POC contains an order for a coude catheter with no balloon size. The POC contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 4: Upon home visit finding, the patient is not taking Sertraline and has not taken it for over a year per the caregiver. This medication remains on the POC. Patient 6: The POC contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 9: The POC 2/27/26 contains an order for Depakote “take 1 tab by mouth Radiology and PVL freq” PVL and Freq are not approved abbreviations and order is unclear. Patient 10: The current POC contains an order for Acetaminophen 650mg every 6 hours prn and 650mg 2 tabs daily prn with no directive for maximum daily limit for acetaminophen. Patient 11: The POC 4/7/26 contains an order for a coude foley catheter with no order for balloon size or order for frequency to change. The POC 3/20/26 contains an order for care of JP drains and biliary drains though does not state who is to perform the cares. Patient 12: The POC 3/7/26 contains duplicate orders for MSW from 3/7/26-3/11/26 for 1 visit every 5 days for 5 days. Patient 14: The POC 4/7/26 contains Acetaminophen 325mg Q4 hours prn and Acetaminophen 500mg every 4 hours prn with no directive for maximum daily limit for acetaminophen. Patient 15: The POC 8/12/25 contains Acetaminophen 650mg every 4 hours prn and Norco 5/325 1 tab every 4 hours prn with no directive for maximum daily limit for acetaminophen.”

“Upon patient record review, 1 of 19 (Patient #10) 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 10: The POC 12/18/25 contains an SBAR by the volunteer that patient requested a volunteer and that volunteer placement is pending until they find a volunteer to assign. There is no order frequency written on the POC for the volunteer. This SBAR continues on each POC update until current and no volunteer was ever scheduled.”

“Upon client record review, 11 of 19 (Patient #2,3,4,6,8,9,10,11,12,13,18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The POC 12/23/25-3/11/26 contains an order for chaplain 4 visits every 30 days for 79 days. The Chaplain had missed 1 visit from 12/23/25-1/21/26, 2 Missed visits 1/22/26-2/20/26 and 2 missed visits 2/21/26-3/11/26. There was no missed visit documentation or evidence of refusal. Patient 3: The POC contains orders for the MSW has to assess community resource needs every visit and on 12/15/25,1/24/26, 2/24/26 this was not completed. Patient 4: The POC 6/12/25 contains an order for SN visit ordered once weekly, from 7/6/25-7/12/25 there is no SN visit completed. The SN is ordered once weekly and no visit made the week of 2/22/26-2/28/26. There was no missed visit documentation or evidence of refusal. Patient 6: The current POC contains an order for MSW 1 visit every week, the week of 4/12/26-4/18/26 there was no visit made and no missed visit documentation or evidence of refusal. The POC 3/5/26 contains an order for the SN to measure MAC every visit, the MAC was not measured on 3/10/26 by the SN. Patient 8: The POC 5/4/25 contains orders for SN twice weekly, the week of 5/4/25-5/10/25 there was no second visit made. The week of 5/25/25-5/31/25 there was no second visit made. There is no missed visit documentation or evidence of refusal. The current POC contains an order to measure MAC every other visit by the SN. The SN measured MAC 3/26/26 and no further MAC measurements have been completed through current. The MSW documented on 3/31/26 “arrived with Licensed Massage Therapist”, there was no order for massage on the POC. Patient 9: The POC 2/27/26 contains an order for SN once weekly. The week of 3/22/26-3/28/26 there was no visit made with and no missed visit documentation and no evidence of refusal. The POC current has orders to assess skin integrity, wound, patient ID, every visit this was not completed on 3/17/26 and 3/30/26. On 4/8/26 the SN did not document against care plan intervention patient ID which is ordered every visit. Patient 10: The 3/15/26 POC contains an order for SN twice weekly, the week of 3/15-3/21/26 there was no second visit made with no missed visit documentation or evidence of refusal. Patient 11: The SN documented on 3/22/26 flushing the biliary drains with 5ml of NS, the order is to flush with 10ml NS. Patient 12: The SN documented on 3/26/26 patient had a fall and an abrasion to the right elbow. The SN educated patient to cover with a dry dressing or band aid. There was no order for this wound care. Patient 13: The POC contains orders on 4/2/26-5/23/26 for 7 SN visits every week for 8 weeks. There were 4 missed visits the week of 3/29/26-4/4/26. The week of 12/1/25-2/22/26 there is an order for 1 visit a week, there was no visit made the week of 2/22/26. There was no missed visit documentation or evidence of refusal. The POC contains orders for chaplain 11/30/25-2/22/26 for 4 visits every 30 days. There was no visit completed the week of 2/22/26-2/28/26 with no missed visit documentation or evidence of refusal. Patient 18: The POC 1/9/25 contains orders for SN 2 times a week for 13 weeks. There was only 1 visit made the week of 1/5/25-1/11/25. The POC contains an order for SN beginning 4/9/25-7/5/25 for SN 1 visit every week for 13 weeks, the week of 4/6/25-4/12/25 there was no visit made. There was no missed visit documentation or evidence of refusal.”

“Upon patient record review 2 of 19 (Patient #10,14) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 10: The POC 12/18/25 contains an SBAR by the volunteer that patient requested a volunteer and that volunteer placement is pending until they find a volunteer to assign. This SBAR continues on each POC update until current and no volunteer was ever scheduled. Patient 14: The SN documented on 3/30/26 that a volunteer was requested. There have been no volunteers sent.”

“Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 7: The aide has not had a competency on reading and recording temperature, pulse and respirations.”

“Upon patient record review 7 of 19 (Patient #5,6,10,11,13,15,18) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 5: The aide POC contains an order for aide twice weekly. The week of 2/22/26-2/28/26 there was no second visit made that week. No evidence of refusal or missed visit documentation. Patient 6:The current aide POC contains orders for aide twice weekly the week of 2/22/26-2/28/26, The aide make only 1 visit. There is no missed visit documentation or evidence of refusal. Patient 10: There is a POC order 12/21/25 for aide visits 3 times weekly. The week of 12/28/25-1/3/26 there were no aide visits made with no missed visit documentation or evidence of refusal. The week of 1/11/16-1/17/26 there was only 2 visits made by the aide and is ordered 3 times a week. The week of 3/8/26-3/13/26 there was no third visit made, 3/22-3/28/26 there was no third visit made. There were no missed visit documentations or evidence of refusals. Patient 11: The aide POC 3/20/26 contains an order for 2 visits every week. The week of 3/20/26-3/21/26 there were no visits made. The week of 4/5/26-4/11/26 there was no third visit made, the week of 4/12/26-4/18/26 there was no third visit made. There was no missed visit documentations or evidence of refusals. Patient 13: The POC contains an order for aide visits twice weekly from 11/25/25-2/21/26. The week of 11/25-11/29/25 there was only 1 visit made. There was no missed visit documentation or evidence of refusal. Patient 15: The aide POC 9/9/25 contains an order for aide visits twice weekly. The aide did not make a second visit the week of 9/7-9/13/25. There was no missed visit documentation or evidence of refusal. Patient 18: The POC 1/9/25 contains an order for Aide care 2 visits every week for 13 weeks beginning 1/15/25-4/8/25, the weeks of 3/16-3/22/25 there were 2 visits missed, the week of 3/23/-3/29/25 there was 1 visit missed. There is an new order beginning 4/9/25-7/5/25 for 2 aide visits every week for 13 weeks. There was no visit completed the week of 4/9-4/12/25. There was no missed visit documentations completed at any of these missed visits or evidence of refusal.”

“Upon patient client record review, 6 of 19 (Patient #1,3,7,9,11,14) 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 1: The SN documented on 4/20/26 cleansing wound but did not document what it was cleansed with. It is unclear if the POC was followed. Patient 3: SN documenting 3/6/26 through current, performing wound care and cleansing wound, the nurse did not document what type of dressing was applied to the wound or what the wound was cleansed with. It is unclear if the POC was followed. Patient 7: The SN documented on 4/21/26 performing wound care as ordered. It is unclear if the SN followed the POC. Patient 9: The SN documented performing “wound care per orders” on 3/12/26, 3/30/26, 4/8/26 it is unclear if the POC was followed. The medical record contains active wounds on the nursing documentation notes with a start date of 1/12/26, patient was admitted to hospice 2/27/26. This should have been resolved when patient was admitted to hospice as this is a wound from the patient’s hospitalization record. Patient 11: The POC 4/7/26 has documentation by the SN performing a procedure on the biliary drains and the patient tolerated the procedure well. It is unclear the SN followed the POC for the biliary drain care ordered. The SN documented 3/23/26 “flushed drains with NS and patient tolerated without diff” It is unclear how much NS was used in the flushes and “Diff” is not an approved abbreviation. The SN documented 3/24/26, 3/26/26 “flushed drains” though did not state which drains were flushed or what the drains were flushed with. It is unclear the POC was followed. Patient 14: The MSW documented on 8/18/26 that patient’s religious background is Pescatarian. This is not a religious affiliation.”