Hospice & Palliative Care of Virginia

“Based on record review, interviews, and policy review, it was determined that the hospice agency failed to ensure that the initial spiritual assessment was completed within five calendar days after the start of hospice for three patients (Patients (P) 3, P4, and P9) of 10 active patients reviewed for spiritual assessments. This failure had the potential to cause patients’ desired wishes not to be honored. Findings include: There was no documented evidence that the hospice agency completed the initial Chaplain assessment within five calendar days after the start of hospice for three patients (P3, P4, and P9). In addition, there was no evidence that the hospice agency had a check and balance system to ensure that these assessments were completed on time. Refer to L523.”

“Based on record review, interviews, and policy review, it was determined that the hospice agency failed to ensure that acceptable standards of practice were maintained to prevent cross-contamination during two of three home visits with two patients (Patients (P) 2 and P6) when gloves were not changed when going from a dirty area to a clean area and patient equipment was not cleaned after usage. In addition, the hospice agency failed to have documented evidence that annual infection control training was completed for two of four employee files reviewed. This failure had the potential for the agency to have an infection control outbreak without staffs knowledge of how to prevent it. Findings include: There is no documented evidence that the hospice agency completed annual infection control training for two of four employee files reviewed. In addition, there is no check and balance system in place to ensure that training is completed for current employees. Refer to L582. The agency failed to implement documented standards of practice to prevent the potential of infections in two of three home visits. Refer to L579.”

“Based on record review, interviews, and policy review, it was determined that the hospice agency failed to ensure that one of 10 patients (Patient (P) 7) had home health aide (HHA) progress notes since admission. In addition, the hospice agency failed to ensure that there was a signed revocation and evidence that attending physician received a copy of the discharge summary for one of four patient (P13) discharges. These failures had the potential for patients to have increased re-admissions and/or for staff not to have knowledge of the patients plan of care. Findings include: There was no documented evidence that the hospice agency had completed progress notes for P7 from the home health aide (HHA) since admission, which was 08/20/24. There was no check and balance system to ensure that each discipline completed their notes in a timely manner. Refer to L672. There was no documented evidence that the hospice agency had a signed revocation for P13 that revoked hospice. In addition, there was no documented evidence that the hospice agency sent P13s attending physician a copy of the discharge summary. Refer to L683.”

“Based on record review, interview, and agency policy review, the hospice agency failed to ensure that an initial spiritual assessment was completed for three of 14 patients (Patient (P) 3, P4, and P9) within five days after the election of hospice care. Findings include: 1. Review of P3s agency provided “Patient Profile” indicated that P3 was admitted to hospice on 05/23/24 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of P3s facility provided “Spiritual Care Assessment,” dated 05/29/24 (six days after the election of hospice care) indicated no evidence that the assessment was completed. During an interview on 12/05/24 at 4:30 PM, the Clinical Director (CD) confirmed that the initial spiritual assessment was not completed and should have been. 2. Review of P4s agency provided “Patient Profile” indicated that P4 was admitted to hospice on 01/10/24 with a diagnosis of protein calorie malnutrition. Review of P4s electronic medical record (EMR) under the tab “Counseling,” indicated no evidence of the initial spiritual care assessment being completed. During an interview on 12/05/24 at 4:33 PM, the CD confirmed that there was no initial spiritual assessment completed. 3. Review of P9s agency provided “Patient Profile” indicated that P9 was admitted to hospice on 05/31/24 with a diagnosis of bladder cancer. Review of P9s facility provided “Spiritual Care Assessment,” dated 06/04/24, indicated evidence that the assessment was incomplete. It was marked the assessment had been opened, dated, and marked as complete. There was no other documentation. During an interview on 12/05/24 at 4:50 PM, the CD confirmed that the initial assessment was incomplete and should have been completed. She confirmed that there was no check and balance to ensure that these assessments are completed. Review of agency policy titled, “Start of Care Visits,” revised 11/18/08, indicated, “. . . The . . . Chaplain . . . no later than five calendar days after the election of hospice care using the initial assessment form appropriate to their discipline . . .””

“Based on observations, interviews, review of the agencys policy, and Centers for Disease Control (CDC) guidelines, the agency failed to implement accepted standards of practice to prevent the potential of transmission of infections and communicable diseases in two of three home visits with two patients (Patients (P) 2 and P6) with Licensed Practical Nurse (LPN) 1 and Certified Nursing Assistant (CNA) 2. This deficient practice had the potential to affect all 10 patients who were currently receiving hospice services. Findings include: 1. During a home visit on 12/04/24 at 10:00 AM, LPN1 took vital sign equipment from her bag which was placed on a barrier and cleaned the equipment prior to using it for P6; however, after using the pulse oximeter, LPN1 did not clean the oximeter and placed it directly back into the bag. 2. During a home visit on 12/04/24 at 11:53 AM, LPN1 and CNA2 were observed completing a bath for P2. LPN1 and CNA2 washed their hands. LPN1 took P2s vital signs, including pulse oximetry, and CNA2 gathered P2s materials for his/her bed bath. After LPN1 took P2s vital signs, LPN1 replaced the pulse oximeter back into the bag without cleaning. CNA2 started washing P2s face first, including his/her ears, and neck. CNA2 patted P2 dry. P2 wanted to be shaved and CNA2 and LPN1 shaved P2. CNA2 washed P2s hair, then washed his/her chest, and washed his/her left leg. P2s hair, chest and left leg were dried. CNA2 washed his/her right leg and dried. CNA2 washed with the same washcloth and did not change her gloves when she went to pat dry these areas. P2 had a catheter, and CNA2 washed his/her perineal front area and catheter tubing, then patted the area dry without changing her gloves. LPN1 and CNA2 moved P2 up in the bed and rolled him/her over to his/her right side, and removed the sheets on the bed, replacing them with new ones, all with the same gloves. Then CNA2 washed P2s back and bottom area. LPN1 placed a hydro foam dressing on P2s bottom for protection, without changing her gloves. LPN1 and CNA2 rolled P2 back over to his/her back, and finished adjusting the new sheets on the bed, all with the same gloves on. When finished, CNA2 and LPN1 removed these gloves and washed their hands. During an interview on 12/04/24 at 12:50 PM, CNA2 and LPN1stated they usually only change gloves when the gloves get dirty either with blood or bowel movement. LPN1 confirmed that the pulse oximeter was not cleaned between patient usage and should have been. Both said that they were unsure what the agencys policy was regarding changing gloves. Interview on 12/05/24 at 4:15 PM, Clinical Director (CD) indicated that staff are to change gloves when going from a dirty area to a clean area. The CD confirmed that all patient equipment such as the pulse oximeter should be cleaned after each use. Review of the hospice agency policy titled, “Infection Control,” revised 11/18/08, indicated, “. . . Procedure: 1. The hospice will utilize Universal Precautions when delivering care to all patients. This will include using recommended hygiene, engineering controls, and personal protective equipment . . .” Review of the CDC website (https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html)”. . . 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices...4.b. Disinfect noncritical medical devices . . . with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions . . .””

“Based on record review, interviews, and agency policy review, the hospice agency failed to ensure that two of four employee files that were reviewed had annual infection control training. Findings include: 1. Review of Certified Nursing Assistant (CNA) 1s employee file indicated no evidence of annual infection control training in calendar year 2023. 2. Review of Licensed Practical Nurse (LPN) 1s employee file indicated that she was assigned infection control training; however, LPN1 did not complete in calendar year 2023. Interview on 12/06/24 at 11:30 AM, the Administrator Assistant, confirmed that there is no check and balance system for the training program. The Administrator Assistant stated that once the employees training was set up for the calendar year, it was the employees responsibility to make sure that the trainings were completed. The Administrator Assistant stated that he/she checked the training periodically but had no set schedule. The Administrator Assistant confirmed that CNA1 and LPN1 did not have the annual infection control trainings in 2023. Interview on 12/06/24 at 3:30 PM, the Clinical Director (CD), confirmed that there was no check and balance system for the employee training program. Review of the hospice agency policy titled, “Infection Control,” revised 11/18/08, indicated, “. . . All employees who have occupational exposure to bloodborne pathogens receive initial and annual training conducted . . . Training records are completed for each employee upon completion of training. These documents will be kept for at least years in the Clinical Department. The training records include: the dates of the training sessions . . . the contents or a summary of the training . . .””

“Based on record review, interviews, and agency policy review, the hospice agency failed to ensure that one of two Certified Nursing Assistants (CNA2) whose employee files were reviewed had at least 12 hours of in-service trainings for calendar year 2023. This had the potential to cause patients to receive unsatisfactory care. Findings include: Review of CNA2s “Employee File,” indicated that CNA2 was hired by the agency on 12/27/04. During further review of online “Certificate of Completion” courses indicated that for the calendar year of 2023, CNA2 had a total of 3.5 hours in the following courses: Perineal and Catheter Care, dated 02/16/23 for one hour; Effective Communication in Home Care and Hospice, dated 03/16/23 for 0.5 hour; How to Recognize and Report Human Trafficking, dated 04/10/23 for one hour; and Using Technology with Seniors, dated 04/12/23 for one hour. During an interview on 12/06/24 at 11:30 AM, the Administrator Assistant confirmed that there was no check and balance system for the agency’s training program. The Administrator Assistant stated that once the employees training was set up for the calendar year, it was the employees responsibility to make sure that the training was completed. He/She stated that he/she checks the training periodically but has no set schedule, and the system does not send reminders to the employees to complete the training. The Administrator Assistant confirmed that CNA2 did not have the required amount of training for calendar year 2023. During an interview on 12/06/24 at 3:30 PM, the Clinical Director (CD) confirmed that there was no check and balance system to ensure that CNAs completed at least 12-hours of in-services in a calendar year. The CD confirmed that CNA2 did not have the required amount of training for calendar year 2023. Review of agency policy titled, “Program Services,” revised 11/18/08, indicated, “. . . Home attendant/Home Aide services . . . Hospice aides shall receive at least 12 hours in-service training during each calendar year . . .””

“Based on record review, interview, and agency policy review, the hospice agency failed to ensure that one of 10 active patients (Patient (P) 7) records contained clinical notes of hospice aide visits. This had the potential for the agency staff not to know their patient and their patients’ desired wants and/or needs. Findings include: Review of the agency provided “Patient Profile” indicated P7 was admitted on 08/20/24 with a diagnosis of larynx cancer. The electronic medical record (EMR) indicated that P7s second recertification period was 08/20/24-11/17/24 and third recertification period started on 11/18/24 and will end on 01/16/25. Review of P7s EMR under tab “Clinical Notes” indicated no evidence of hospice aide notes since admission, which was 08/20/24. Interview on 12/05/24 at 4:40 PM, the Clinical Director (CD) confirmed that P7s medical record had no hospice aide notes. The CD stated that there should be something since P7 is in his/her third recertification period, and that the hospice aids have seven days to complete their notes and get them in. The CD stated there was no check and balance system to keep track of these notes. Review of agency policy titled, “Documentation,” revised 09/01/98, indicated, “. . . Documentation will provide evidence of the course of the patients medical evaluation, treatment, and change in condition while being followed in the program . . . 3. Understand that documentation of the patients care must be written and submitted within seven (7) days of the service being rendered . . .” Review of agency policy titled, “Clinical Records,” revised 10/04/01, indicated, “. . . An adequate medical record shall be maintained for each individual who receives services in the program according to accepted practice. The clinical record shall contain pertinent identifying information, description of the patients problems and needs, justification for hospice care, documentation of care provided, and the results of that care. Clinical records . . . Signed and dated progress notes by each individual delivering services shall be written on the day the service is delivered and incorporated in the medical record within seven working days . . .””

“Based on record review, interview, and agency policy review, the hospice agency failed to ensure that one of 10 (Patient (P) 13) active patients that revoked hospice had a signed revocation. In addition, the hospice failed to ensure that P13s attending physician was given a copy of the hospice discharge summary. This failure had the potential for a re-admission to the hospice agency. Findings include: Review of the agency provided “Patient Profile” indicated that P13 was admitted to the hospice agency on 09/23/24 for a diagnosis of end stage chronic obstructive pulmonary disease (ES COPD). Review of the agency provided “Hospice Discharge Summary,” dated 11/07/24, indicated, “[P13] revoked to seek aggressive treatment.” Review of P13s electronic medical record (EMR) indicated no evidence of a written and/or signed revocation. There was no evidence that P13s attending physician was notified of revocation. Interview on 12/05/24 at 5:00 PM, the Clinical Director (CD) confirmed that there was no signed revocation form from P13 and that P13s attending physician was not notified of discharge. The CD stated that the hospice agency received a call from the family that P13 was going to receive aggressive treatment and since then they had been unavailable to sign a revocation. The CD confirmed that there was no evidence in the medical record where the hospice agency had attempted to contact P13 to sign the revocation without success. Review of the agencys policy titled, “Revoking the Election of Hospice Benefits,” revised 11/27/07, indicated, “. . . To regain standard Medicare benefits, the patient or patients representative must sign a formal revocation of election of Medicare Hospice Benefits which can transmitted to the Medicare Intermediary in order to implement the reinstatement of standard Medicare benefits for the patient. Procedure . . . 3. Signature of Revocation: a. The patients signature is the preferred signature . . . 4. Notification: Hospice nurse, social worker, or other staff member receiving a signed revocation statement will notify the patient care director and the attending physician immediately . . .””