Hospice of Virginia

“Upon patient record review, 1 of 5 (Patient #4) 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 4: The SN documented o 4/12/26 that the sites for the G tube and biliary drain had been healed and the care plan inactivated. There is evidence the patient does still has a G tube that requires tube feeding continuously nightly and patient still has a biliary drain as evidenced by documentation on 5/10/26 by the SN that a PRN visit was made due to biliary insertion site saturated the bedsheets, the caregiver is flushing the drain with saline, and the drain is requiring changing gauze dressing 2-4 times daily. There is no evidence that SN assessed the biliary site drain or the G tube drain since 4/12/26 and it is ordered to be assessed weekly with dressing changes to both sites by SN or caregiver weekly. There is no documentation to support the caregiver or SN provided care to the sites until the 5/10/26 visit.”

“Upon client record review, 2 of 5 (Patient #3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The POC contains an order to insert a 16fr catheter on 4/18/26 and change every 30 days and PRN for leakage, obstruction or incontinence, the SN documented inserting an 18 French foley catheter on 4/10/26 prior to the order being received. The SN documented changing foley on 4/28/26 with no evidence of an order to change early or evidence the foley was leaking, had obstruction or that patient was having any incontinence. Patient 4: The medical record contains an order on 4/8/26 for SN or caregiver to wash bile drain with soap and water and change the dressing weekly. There is no documentation from 4/21/26 until 5/10/26 that care was performed to this site. There is also an order for G tube site care 4/8/26 weekly by SN or caregiver. This has not been completed from 4/26/26 through current.”

“Upon patient client record review, 2 of 5 (Patient #3,5) 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: The SN documented on 4/14/26 and 4/17/26 “foley to be changed on Friday”. The foley was not due to be changed and was not changed 4/17 which was the Friday the documentation would be referring to. As of 4/24/26 the insertion date is still documented as 4/10/26 for this foley. SN documented on 5/9/26 foley was flushed and patient tolerated well it is unclear what the foley was flushed with. Patient 5: Wound care performed on 5/1/26, 5/4/26, 5/6/26 documented as the written order and then the SN documented “wound provided by SN as ordered.” It is unclear if the SN followed the POC as the wound care is not written in past tense to clarify that the wound care was completed.”

“Upon patient record review, 11 of 23 (Patients #1,#2,#4,#6,#7,#9,#10,#14,#15,#16,#17) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained a lidocaine topical patch with no area defined for administration. Patient 2: The medication profile contained cephalexin as a current medication. The medication order on 3/3/26 was for seven days of administration. During the home visit medication reconciliation, the facility medication profile contained acetaminophen PRN and bisacodyl suppository PRN that were not on the hospice profile. The facility also had differing doses for bumetanide 0.5mg instead of hospice 1 mg, lactulose 10ml instead of 15ml, ondansetron every 6 hours PRN instead of every 4 hours PRN, oxygen 2-5 LPM instead of 2 LPM, and micanazorb powder instead of ointment. Patient 4: The medical record contained nursing documentation 2/24/26 identifying oxygen ordered for delivery. There was no evidence of oxygen included on the medication profile. Patient 6: The medication profile contained lispro insulin with no dose or frequency. Patient 7: The medical record contained nursing documentation 2/17/26 identifying patient use of Biofreeze for pain. The medication profile did not contain Biofreeze. Patient 9: The medication profile contained duplicative listings of scheduled Risperdal. Patient 10: During home visit medication reconciliation, the patient denied having any albuterol inhaler or acetaminophen suppositories in the home that were on the medication profile. The profile also contained inaccurate dose and frequency of NAC supplement listed as 600 mg twice daily however patient confirmed taking 1200 mg once daily. Patient 14: The medication profile contained two differing doses of Lasix without instruction to specify that one was intended as a PRN and the other was scheduled. Both were listed as scheduled daily. Patient 15: The medication profile contained Jevity with no instructions for bolus or timed feeding. Patient 16: The medical record contained nursing documentation 3/13/26 identifying patient use of oxygen. There was no oxygen listed on the medication profile. Patient 17: The medication profile contained Januvia with no frequency.”

“Upon patient record review, 1 of 23 (Patient #6) 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 6: There was no evidence of wound assessments from admission 1/6/26 to 3/6/26 and measurements from admission to 3/13/26. Per agency policies 4-120 and 4-121, documentation of wound status is required at a minimum of once per week.”

“Upon patient record review, 9 of 23 (Patients #1,#3,#7,#8,#10,#12,#15,#17,#18) 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 medical record indicated patient was on services for complications related to a CVA and diagnosis of dementia. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Patient 3: The medical record indication patient was on services for complications related to a CVA and diagnosis of a seizure disorder. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient diagnoses of atrial fibrillation, hypertension, and bradycardia. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care. Patient 8: he medical record indication patient was on services for heart disease. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care. Patient 10: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia and risk for falls. There was no evidence of problems, goals, and interventions related to dysphagia and fall safety included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient issues with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Patient 15: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Patient 17: The medical record contained nursing documentation upon admission identifying patient diagnosis of hypertension and atrial fibrillation. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care. Patient 18: The medical record contained nursing documentation upon admission identifying patient diagnosis of bradycardia. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care.”

“Upon patient record review, 10 of 23 (Patients #1,#2,#4,#5,#6,#7,#13,#15,#16,#17) 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 medical record contained an order for lidocaine topical patches with no area defined for administration. Patient 2: During the home visit medication reconciliation, the facility medication orders contained acetaminophen PRN and bisacodyl suppository PRN that were not in the hospice record. The facility also had differing doses for bumetanide 0.5mg instead of hospice 1 mg, lactulose 10ml instead of 15ml, ondansetron every 6 hours PRN instead of every 4 hours PRN, oxygen 2-5 LPM instead of 2 LPM, and micanazorb powder instead of ointment. Patient 4: The medical record contained nursing documentation 2/24/26 identifying oxygen ordered for delivery. There was no evidence of an order for oxygen rate, frequency, and delivery method. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a CPAP. There was no evidence of an order for CPAP use parameters. Patient 6: The medical record contained an order for lispro insulin with no dose or frequency. Patient 7: The medical record contained nursing documentation 2/17/26 identifying patient use of Biofreeze for pain. There was no evidence of an order for Biofreeze. Patient 13: The medical record contained nursing documentation 3/1/26 and 3/10/26 identifying the nurse completed wound care. There was no evidence of an order for wound care. Patient 15: The medical record contained an order for Jevity with no instructions for bolus or timed feeding, and there were no tube feeding maintenance or insertion site care orders. Patient 16: The medical record contained nursing documentation 3/13/26 identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 17: The medical record contained an order for Januvia with no frequency.”

“Upon patient record review, 9 of 23 (Patients #1,#4,#5,#6,#7,#13,#14,#15,#16) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation 3/9/26 identifying patient us of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Patient 4: The medical record contained nursing documentation 2/24/26 identifying oxygen and a nebulizer were ordered for delivery. There was no evidence of an order for the DME included in the plan of care. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a CPAP and a cane since 2/25/26. There was no evidence of orders for the DME included in the plan of care. Patient 6,7: The medical record contained nursing documentation since admission identifying patient use of bedrails. There was no evidence of an order for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation 1/20/26 identifying patient use of bedrails, APP mattress, walker, wheelchair, and overbed table. There was no evidence of orders for the DME included in the plan of care. Patient 14: The medical record contained an order for nebulized albuterol. There was no evidence of an order for the nebulizer included in the plan of care. Patient 15: The medical record contained nursing documentation since admission identifying patient use of a walker, APP mattress, and tube feeding supplies. There was no evidence of orders for the DME included in the plan of care. Patient 16: The medical record contained nursing documentation 3/13/26 identifying patient use of an oxygen concentrator, commode, trapeze, walker, and wheelchair. There was no evidence of orders for the DME included in the plan of care.”

“Upon patient record review, 2 of 23 (Patients #3,#14) 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 3: The medical record contained documentation identifying patient was receiving volunteer services. There was no evidence the plan of care was updated to include the problems, goals, and interventions related to volunteers. Patient 14: The plan of care contained problems, goals, and interventions related to the need to discharge from hospice since 5/27/25. There was no evidence the plan of care was updated to remove the care planning.”

“Upon client record review, 3 of 23 (Patients #2,#13,#16) 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 medical record contained an order for spiritual care visits twice monthly. There was no evidence of a second visit completed in February. Patient 13: The medical record contained nursing documentation 3/1/26 and 3/10/26 identifying the nurse completed wound care. There was no evidence of an order for wound care. Patient 16: The medical record contained an order for spiritual care visits twice monthly. There was no evidence of a second visit completed in January.”

“Upon patient record review, 13 of 23 (Patient #1,#2,#3,#6,#7,#8,#11,#12,#13,#15,#16,#17,#18) did not have evidence the hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: 1. All physician employees and those under contract must function under the supervision of the hospice medical director. 2. All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. 3. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. Patients 1,2,6,7,8,11,12,13,15,16,17: The medical record identified that hospice physicians were acting as the attending physician. There was no evidence of the Medical Director having oversight of the hospice physicians. Patients 3,18: The medical record and election forms identified the patient elected a community physician as the attending physician, and a hospice physician involved with care and documentation for certification and IDG participation. There was no evidence of the Medical Director having oversight of the hospice physicians.”

“Upon patient record review, 1 of 23 (Patient #21) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved Patient 21: There was no evidence of a bereavement task of phone call at 6 months to the patient’s friend and no bereavement tasks completed for the patient’s spouse.”

“Upon patient record review 4 of 23 (Patients #2,#6,#11,#15) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 2: The medical record contained an order for aide visits three times weekly. There was no evidence of third visits completed the weeks of 2/8/26, 2/22/26, and 3/8/26. Patient 6: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 1/25/26. Patient 11: The medical record contained an order for aide visits five times weekly. There was no evidence of a fifth visit completed the week of 2/8/26. Patient 15: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 3/1/26.”

“Upon patient client record review, 2 of 23 (Patients #7,#21) 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 7,21: The medical record contained an incomplete DNR form with sections 1 and 2 left blank where it is to be identified whether the patient is capable for signing for themselves or an explanation of why the responsible party is signing on their behalf.”