Desert Valley Hospice LLC

“Upon patient record review, 7 of 19 (Patient #2,3,4,5,8,9,11) 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: Patient 2: Upon home visit finding, the agency medication profile contains Refresh tears 2 drops daily in am with no directions for which eye. Miralax powder 17 g 1 dose orally daily PRN with no dose amount details and no dose dilutant noted. Corrected on site. Patient 3: Upon home visit, facility medication profile contains orders for Ketoconazole shampoo and Bacitracin ointment order PRN with treatment plan to apply topically to open area PRN daily after cleaning area with wound cleanser/NS and Nonstick dressing. Ketoconazole shampoo was not on agency med profile and the wound care treatment had been discontinued in agency orders. Corrected on site. Patient 4: Upon home visit, noted on agency medication list contains Miralax powder 17 gms dose powder daily PRN with no dose and no dilutant and Nystatin 100,000u/g dose 1 apply topically under both breasts BID until rash resolved. POC on 4/25/25 contains a treatment for Rash under breast apply antifungal powder 2x /day until rash resolved with no clear directions for dose. The Assisted living medication profile contains an order for Ondansetron Oral tablet 4mg every 8 hr PRN not present on the agency medication profile. Corrected on site. Patient 5: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 8: The medication profile contains Fluoxetine 1 “Ablet” oral daily. Corrected on site. Patient 9: The medication profile contains Miralax with no diluent. Morphine sulfate ordered 20mg every 8 hour as needed with no reason. Tylenol is ordered 500mg two tabs three times daily routine and 325mg 2 tabs every 6 hours as needed there is no maximum allowable amount daily. Corrected on site. Patient 11: The medication profile contains Lidocaine top cream dose 4% apply to knees every 8h prn with No dose amount specified. There is evidence in SN documentation on 4/30/25, “Pt uses CPAP for sleep apnea at night.” There is no evidence of CPAP orders. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #17, 19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 17: There was no evidence of initial bereavement assessment. Patient 19: There was no evidence of an initial bereavement assessment.”

“Upon patient record review, 1 of 19 (Patient #7) 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: SN documented 4/26/25 “caregiver reports patient may have wax impaction in her ear canals affecting her hearing. RNCM to follow up next week.” There is no evidence of follow up by RN”

“Upon patient record review, 3 of 19 (Patient #5,7,11) 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 SN documented on 4/30/25, 5/21/25 “She is a high fall risk”. There is no nursing care plan for risk of falls with goals or interventions on the POC. Corrected on site. Patient 7: The Medical director documented on the CTI 4/16/25 that patient “has increasing dysphagia with swallowing and eating and has increased coughing episodes”. There was no care plan with goals and interventions put in place for risk of aspiration. Corrected on site. Patient 11: The SN documented pt has dysphagia on the comprehensive assessment 1/22/25. The 5/29/25 has a diet order for diet as tolerated with thin liquids related to dysphagia. Aspiration precautions continue to be ordered on the Aide POC but there is no risk for aspiration care plan with goals and interventions on the POC. Corrected on site.”

“Upon patient record review, 8 of 19 (Patient #2,3,4,5,8,9,11,12) 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 medications and treatments. Patient 2: POC 5/7/25 Miralax powder 17 g 1 dose orally daily PRN with no dose amount details and no dose dilutant noted. Corrected on site. Patient 3: The POC does not contain orders found at assisted living facility medication profile including orders for Ketoconazole shampoo and Bacitracin ointment order PRN with treatment plan to apply topically to open area PRN daily after cleaning area with wound cleanser/NS and Nonstick dressing. Ketoconazole shampoo was not on agency med profile and the wound care treatment had been discontinued in agency orders. The medical record contains evidence pt has skin tear wounds. There was no wound care plan orders on the POC. Corrected on site. The IDG note 5/29/25 the SN documented pt using Tubi grips for compression and a SN note on 4/18/25 the SN documented pt using Tubi grips for compression. There is no directive in the order for how long the patient is to where them daily they are only mentioned in IDG by the RN. The POC has not been updated to include these orders. Patient 4: The POC on 4/25/25 contains Nystatin 100,000u/g dose 1 apply topically under both breasts BID until rash resolved. POC on 4/25/25 contains a treatment for Rash under breast apply antifungal powder 2x/day until rash resolved with no clear directions for dose. There is evidence of skin tear treatment order at the facility including Bacitracin to skin tear and no evidence of skin care treatment noted at hospice agency record. Corrected on site. Patient 5: the POC 1/29/25 contains an order for Miralax with no diluent. Corrected on site. Patient 8: The POC contains Fluoxetine 1 “Ablet” oral daily. Corrected on site. Patient 9: The POC 11/4/24 contains Miralax with no diluent. Morphine sulfate ordered 20mg every 8 hour as needed with no reason. Tylenol is ordered 500mg two tabs three times daily routine and 325mg 2 tabs every 6 hours as needed there is no directive for maximum allowable amount. Corrected on site. Patient 11: The POC 5/29/25 contains Lidocaine top cream dose 4% apply to knees every 8h prn No dose specified. There is evidence in SN documentation on 4/30/25, “Pt uses CPAP for sleep apnea at night.” There are no CPAP orders on the POC. Corrected on site. Patient 12: The POC 2/13/25 contains the following wound orders “#1, Open Hip-left stage 11 wound existing*************** Cleanse with wound wash and pat dry. Apply composite dressing to area. SN to complete weekly. GH PRN if dressing is soiled/removed. Sacral wound ***********keep sacral wound area dry/clean. Apply Calmoseptine topical ointment dose 1 application once daily and as needed. To be completed by SN and GH staff. Abrasion/excoriation, groin abrasion**********Keep abrasion area dry/clean. Apply Calmoseptine to affected area once daily and PRN. To be completed by SN and GH staff.” The wound orders do no contain clear directions and contain use of non approved abbreviations. Corrected on site.”

“Upon client record review, 7 of 19 (Patient #1,3,4,5,7,8,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: 4/24/25 The volunteer documented “I brought patient a chicken sandwich, he loved it.” The Volunteer instructions do not include delivering meals or any diet orders. Patient 3: The POC contains an order for SN once per week and 2 PRN. The SN has made 5 prn visits from 4/18-5/22/25 to the patient this certification period for increased edema and has not updated the POC to include increasing nursing visits to twice weekly or increased orders for PRN visits completed. They have orders for 2 prn visits. Patient 4: The POC 4/3/25 contains an order for “RN once per week” and the LVN saw the patient 4/10/25. There were no orders for the LVN to see the pt. Patient 5: The SN documented on 5/8/25 “Pt has multiple skin tears to arms. Areas clean and left open to air per staff request.” There is no evidence the SN informed the MD about these new skin tears until the IDG note on 5/15/25 the SN documented pt has skin tears to arms. There is no evidence of orders for care of skin tear. Patient 7: The SN documented on 4/29/25 “instructed patient to apply cold compress 15min on and 15 min off to foot alternating until comfort achieved.” There is no evidence of an order for this modality. Patient 8: The SN documented on 4/15/25 “urine dipstick was obtained with positive nitrates and leukocytes today. Dr notified”. There is no evidence of an order for a urine dipstick to be performed. Patient 14: The volunteer documented “Took chocolates. She didn’t want it but left it anyway.” on 4/8/25. Delivering meals/food is not ordered on the volunteer task sheet.”

“Upon patient record review 1 of 19 (Patient #7) 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 7: SN note 4/28/25 SN note “inquired about triage call regarding anxiety over verbal conflict regarding patient and neighbor”. Communication note 4/29/25 caregiver states “pt having pain in her foot and would like a visit.” Inquired as to future plans for when pt is total care and NWB and needing 24/7 care/supervision. POA stated “no idea, I figured hospice would help” Caregiver indicated she cannot give patient 24/7 care. The hospice documented they “referred to the social worker to reach out that day to discuss future plans.” The SN documented on 5/7/25 “reviewed need for custodial care 24/7 for safety concerns w pt alone 90% of the time. POA states she is talking w SW re: options.” The social worker did not visit until 5/28/25 and there was no evidence of discussion about future plans for needed 24/7 care. There is no evidence of this information being discussed at IDG.”

“Upon patient record review, 9 of 19 (Patient #1,2,3,5,6,7,8,9,10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: Aide POC 2/14/25 has Assist with feeding and change linens with no frequency. Corrected on site. Patient 2: Aide POC 7/29/24 has change pt linens with no instruction for frequency. Corrected on site. Patient 3: Aide POC 4/2/25 has change linens with no frequency. Corrected on site. Patient 5: The Aide POC 3/10/25 contains an order to change patient Linens with no frequency. Corrected on site. Patient 6 : Aide POC 4/17/25 has change pt linens with no frequency. Corrected on site. Patient 7: Aide POC 4/16/25 has change pt linens with no frequency. Corrected on site. Patient 8: Aide POC 11/19/24 has change pt linens with no frequency. Corrected on site. Patient 9: Aide POC 2/12/15 has change pt linens with no frequency. Corrected on site. Patient 10: Aide POC 4/24/25 contains turn and reposition and change patient linens with no frequencies. The aide POC 4/24/25 contains a directive for bleeding precautions, there is no evidence of bleeding precautions on the POC. Corrected on site.”

“Upon patient record review 3 of 19 (Patient #2,6,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: Aide visit documentation not completed on 7/31/24 indicating no tasks were completed. There was a narrative note at the bottom that “shower was refused and pt was Shaved per HHA” with no ordered task for shaving noted on aide POC. There was no evidence of any of the other ordered tasks being refused. Patient 6: The POC 4/17/25 contains an order for aides twice weekly. The aide did not see the patient until 4/22/25. There is no evidence of refusal or missed visit documentation. Patient 10: The POC 4/25/25 contains an order for aides twice a week. The aide did not make the first visit until 4/29/25 there was no visits made the week of 4/25/25. There was not missed visit documentation or refusal.”

“Upon patient client record review, 10 of 19 (Patient #1,2,5,7,9,10,11,12,18,19) 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 6/2/25 “AAOx3” Per agency approved abbreviations policy the correct abbreviation for this would be A&Ox3. Also documented was “BBS diminished”. This is not approved.5/19/25 the SN documented “VSS”. This is not an approved abbreviation. Patient 2: The SN documented on 5/30/25 “Prn senna and Miralax given” There is no evidence of what dose was given. On 5/28/25 the SN documented “Tylenol given during visit.” There is no evidence of dose was given. Patient 5: The SN documented on 1/29/25 “GH will transfer pt bed/chair.” GH is not an approved abbreviation. The SC documented on 5/19/25 “GHO”. This is not an approved abbreviation. On 5/8/25 the SN documented “dtr” this is not an approved abbreviation. Patient 7: The SN documented 5/7/25 “approp”, “skin CSI/pale”, “w”, “admin med”, “verb”, “Avail”. 5/21/25 SN documents “w”, “b/b”. These are not approved abbreviations. Patient 9: The SN documented on 5/21/25 “LS are CTA bilaterally” 5/28/25 The SN documented “lungs are CTA bilaterally. AP is regular.” These are not approved abbreviations. Patient 10: The MSW documented on 4/28/25 “GHO and GH” these are not approved abbreviations. The SN documented 5/13/25 “CTA bilaterally. AP regular” “CG”. These are not approved abbreviations. The SN documented on 5/2/25 “dtr” updated on visit. This is not an approved abbreviation. Patient 11: The SN documented “d/t” and “w/”, in the narrative on 5/30/25. This is not an approved abbreviation. On 5/27/25 the SN documented “BGL”. Patient 12: SN documents on 4/22, 4/29, 5/6/25 “wound care provided per orders” It is noted that wound to left hip is documented resolved 4/15/25. Patient 18: The SN documented on 5/30/24 “verb understanding”, “VSS”, “w”, “avail”. 6/3/25 The SN documented “liq”, “C2 for Oxy for today delivery” SN doc on 6/3/24 use of unofficial abbreviations including no interaction since Saturday…reviewed ‘gone from my sight’ booklet. Lungs CTA, skin CDI…currently NO MOTTLING OBSERVED….reviewed EOL. These are not approved abbreviations. Patient 19: The SN documented on 6/10/24 “AAOx1”, “BBS shallow”, “PCG”, these are not approved abbreviations.”

“Upon client record review, 2 of 19 (Patient #15,16) did not have evidence that the discharge summary includes all required information. Patient 15: The discharge summary did not contain evidence that the following required information was provided to the emergency room when patient revoked hospice for more aggressive treatment: A summary of the patient’s stay, including treatments, symptoms and pain management, The patient’s current plan of care, The patient’s latest physician orders, Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Patient 16:The discharge summary did not contain the following required information when patient moved out of the area: A summary of the patient’s stay, including treatments, symptoms and pain management, The patient’s current plan of care, The patient’s latest physician orders, Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. There is evidence that agency did have a PIP addressing the discharge process that was closed one day prior to this discharge.”

“Upon client record review, 1 of 19 (Patient #11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 11: The volunteer documented bringing the patient burger, fries and a milkshake on 5/28/25, and a milkshake on 5/21/25. Delivering meals is not ordered on the Volunteer task sheet. Pt is a risk for aspiration with a thinned liquid order and this was not included on the volunteer task list.”