James River Home Health and Hospice

“Upon patient record review, 3 of 19 (Patient #1,#2,#11) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The medication profile indicates there are active medications including ipratropium 0.5mg-albuterol 3ml nebulizer every 4 hours for shortness of breath PRN and for albuterol sulfate 2.5mg/3ml nebulizer every 4 hours for shortness of breath PRN. There is no evidence of instructions on when to take which medication or if they can be taken close together. Patient#2: The patient’s medication profile includes polyethylene glycol and senna 8.6mg. Both medications are ordered as PRN for constipation. There is no evidence of instructions on which medication to take first or if patient can take together. Patient#11: The medication profile indicates patient is using thera calazinc 3%-20% topical two times per week per instructions. There is no evidence of a specified area of application.”

“Upon patient record review, 2 of 19 (Patient #2,#5) 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#2: On 5/28/26 the aide documented the patient had a bruise to arm and was holding arm like it was hurting. Aide also documented reporting this to the RN. There is no evidence of documentation that the RN followed up regarding this. Patient#5: The record indicates patient has wound to right heel which required treatment starting on 4/17/26. There is no evidence of wound measurements from 4/19/26 - 5/18/26.”

“Upon patient record review, 5 of 19 (Patient #5,#6,#8,#12,#14) 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#5: The record indicates patient takes medication for seizures and has a wound to the right heel. There is no evidence of seizure precautions or wound care problems goals or interventions on the plan of care. Patient#6: On 3/23/26 the nurse documents the patient requires soft foods and she educated on aspiration precautions. There is no evidence of aspiration precautions on the plan of care. Patient#8: The record indicates the patient is receiving MSW services. However, there is no evidence of goals or interventions for the MSW on the plan of care. Patient#12: The record indicates the patient is receiving chaplain and social worker services. The initial plan of care states MSW and chaplain to develop plan of care. There is no evidence of goals or interventions on the plan of care for MSW or chaplain. Patient#14: The record indicates the patient has a Trilogy in the home. There is no evidence of problems goals of interventions related to respiratory or the Trilogy on the plan of care.”

“Upon patient record review, 4 of 19 (Patient #1,#2,#5,#11) 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 record indicates there are active orders for ipratropium 0.5mg-albuterol 3ml nebulizer every 4 hours for shortness of breath PRN and for albuterol sulfate 2.5mg/3ml nebulizer every 4 hours for shortness of breath PRN. There is no evidence of instructions on when to take which medication or if they can be taken close together. Patient#2: The patient is ordered polyethylene glycol and senna 8.6mg. Both medications are ordered as PRN for constipation. There is no evidence of instructions on which medication to take first or if patient can take together. Patient#5: There is no evidence of an order for wound care for right heel wound. The nurse does document that the facility has an order. Patient#11: The medication order indicates patient has an active order for thera calazinc 3%-20% topical two times per week per instructions. There is no evidence of a specified area of application.”

“Upon patient record review, 4 of 19 (Patient #2,#3,#6,#12) 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#2: The record indicates patient uses a nebulizer and a wheelchair. There is no evidence of a nebulizer or wheelchair on a DME/supply order for the plan of care. Patient#3:The record indicates the patient uses oxygen, wheelchair, and hospital bed. There is no evidence of a DME order on the plan of care for these items. There is evidence of an active order on the plan of care for wound care supplies. However, the record indicates patient no longer uses wound care supplies. Patient#6: The record indicates the patient uses a hospital bed, over the bed table, and a walker. There is no evidence of an order that includes these items on the plan of care. Patient#12: The record indicates the patient is wheelchair bound. However, there is no evidence of a wheelchair on a DME order for the plan of care.”

“Upon patient record review, 3 of 19 (Patient #5,#6,#12) 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#5: The record indicates on 6/3/26 nurse documented patient having increased cough and aspiration with all meals. It is also documented that patient refuses puree foods and thickened liquids. It is also documented on 5/7/26 and 5/18/26 that nurse to develop plan of care for wound. There is no evidence of any updates on the plan of care regarding these patient changes or needs. Patient#6: On 5/27/26 the nurse documents patient has increase in muscle jerking that now requires patient to take muscle relaxer. On 6/5/26 the nurse documents patient having issues with balance that now requires patient to use a walker and the patient is having trouble swallowing. There is no evidence of updates to the plan of care regarding these changes in patient condition/needs. Patient#12: The nurse documents on IDG 6/3/26 that patient now requires use of compression stockings. Nurse also documents on 4/21/26 patient having increased edema to legs, and on 5/7/26 documents patient having right foot edema. It is also documented that patient has a history of bipolar. One 4/13/26 the nurse documents patient has been combative with staff at adult daycare, on 5/12/26 documents uncooperative episodes reported by daycare staff, and on 5/19/26 patient having yelling outburst with daycare staff. There is no evidence of updates made to plan of care regarding these changes in patient condition/needs.”

“Upon patient record review, 5 of 19 (Patient #1,#5,#7,#11,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: The record indicates patient takes medication for anti-coagulation and seizures. there is no evidence of bleeding precautions or seizure precautions on the aide plan of care. Patient#5: There is no evidence of fall precautions, seizure precautions, skin precautions, or aspirations precautions on the aide plan of care. There is also no evidence of wound notification on the aide plan of care. Patient#7: There is no evidence of oxygen precautions, skin precautions, or aspiration precautions on the aide plan of care. Patient#11: There is no evidence of fall precautions or skin precautions on the aide plan of care. There is no evidence of wound notification on the aide plan of care. Patient#13: There is no evidence of fall precautions or oxygen precautions on the aide plan of care.”

“Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient#5: There is no evidence regarding the wound care for patient that identifies which provider is responsible for this care on the plan of care. There is no evidence of collaboration with hospice and facility regarding the wound care.”