Personal Touch Home Care & Hospice-Newport News

“Upon patient record review, 1 of 14 (Patients #1) did not contain evidence that the Hospice had 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 RN SOC assessment reflected that the patient had a pacemaker. This was not included on the POC.”

“Upon patient record review, 2 of 14 (Patient #7,8) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions; specifically including medications and treatments: Patient #7: The RN SOC assessment reflected that the patient had a 16F 10cc foley in place. The POC dated 10/08/25 to 01/05/26 contained only, “SN assess function of indwelling foley and drainage system.” This is an incomplete order, as it does not include the foley size, balloon, who in the home will be providing monitoring and maintenance of such foley, and the produced urine. Patient #8: A verbal order was obtained on 10/10/25 for, “CPAP minimum/maximum pressure range of 10-20 cm, with heated humidifier, and full face mask”. This treatment was not included on the IDG POC dated 11/07/25.”

“Upon patient record review 3 of 14 (Patients #2, 9, and 10) did not contain documented evidence that a Registered Nurse had made 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 to ensure that services ordered by the Hospice Interdisciplinary Group was meeting these patients’ needs: Patient #2: The first documented aide visit was made on 10/31/2025. As of the date of survey 11/19/25 there had been no aide supervisory visits documented. Patient #9: The first documented aide visit was made on 10/16/2025. As of the date of survey 11/19/25 there had been no aide supervisory visits documented. Patient #10: Multiple aide visits were made between 10/16/25 and 11/19/25. As of the date of survey 11/20/25 there had been no aide supervisory visits documented.”

“Upon personnel and contract review, 1 of 2 (Alternate Medical Director) there was not evidence that the hospice had an employee or contracted individual, to fulfill the role(s) of both Medical Director and Alternate Medical Director. Upon interview with the Administrator, he reported that their Medical Director had resigned such position/role in 08/2025. At that time, the then Alternate Medical Director was re-contracted with to fulfil the Medical Director position; then leaving no one to fulfil the position/role of Alternate Medical Director. The Administrator reports that the hospice has been actively recruiting for this Alternate Medical Director position. This was corrected on-site.”

“Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that the Hospice had obtained, no later than 2 calendar days after Hospice care was initiated, an oral or written certification of the terminal illness by the Hospice Medical Director: Patient #4: SOC 07/30/25. The initial certification of terminal illness by the Medical Director had been dated by the physician as of 08/13/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was initiated.”

“Upon patient record review, 2 of 14 (Patients #4 and 6) did not contain evidence that before the recertification period for each patient, the Medical Director or Physician Designee had reviewed these patients’ clinical information and provided written documentation that it is anticipated that these patients’ life expectancy is 6 months or less: Patient #4: For the recertification period of 10/28-12/26/25, the hospice Medical Director or designee, had not completed the re-certification in a timely manner. The Medical Director had not dated his signature on this CTI form. Nor was there evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. Patient #6: For the recertification period of 03/17-05/15/25, the Medical Director had dated his signature on the CTI as 03/20/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 05/16-07/14/25, the Medical Director had dated his signature on the CTI as 06/06/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 07/15-09/12/25, the Medical Director had dated his signature on the CTI as 07/22/25. There was no evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued. For the recertification period of 09/13-11/11/25, the Medical Director had not yet dated his signature on the CTI form, nor was there evidence of an an oral or written certification of the terminal illness having been obtained no later than 2 calendar days after hospice care was to be continued.”