Green Valley Hospice & Palliative Care, LLC

“Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial and recertification assessment for one of five sampled patients (Patient 1) when during a home visit, medications available in the Patient 1’s home did not match those listed on the Medication Profile (MP).This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy, which could place Patient 1’s health and safety at risk. Findings:A review of Patient 1’s face sheet (document that gives a summary of patient’s information), indicated a start of care date of July 23, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of July 23, 2026, to October 10, 2026. Further review indicated Patient 1 had primary diagnoses that included malignant neoplasm of lower lobe, left bronchus or lung (a cancerous tumor growing in the lower part of the left lung or its airway)During a home visit observation on August 4, 2026, at 11:40 AM, with Medical Social Worker (MSW), in the presence of Patient 1 and Patient 1’s wife, Patient 1’s actual medication bottles, which were available at home, were compared with Patient 1’s most current MP.During a concurrent observation and interview on August 4, 2026, at 11:45 AM, with MSW, MSW checked a bottle of Atorvastatin (a prescription medication used to lower cholesterol and reduce the risk of heart disease). MSW reviewed and acknowledged Atorvastatin was not in Patient 1’s MP.During an interview on August 4, 2026, at 11:50 AM, with Patient 1’s and Patient 1’s wife, Patient 1’s stated, “...had been taking Atorvastatin since long before starting hospice (care that helps people with a terminal illness feel comfortable and supported in their final stages of life) ... doctor is aware of it.”During further concurrent observation and interview on August 4, 2026, at 11:55 AM, with MSW, MSW verified that Ambien (a prescription medication used to treat insomnia by helping people fall asleep faster and stay asleep through the night) 5 milligram (mg-unit of dosing medication), one tablet by mouth, was listed as an active medication that Patient 1 was taking in the MP.During an interview on August 4, 2026, at 12:05 PM, with Patient 1’s wife, Patient 1’s wife stated, “...has never taken Ambien. The visiting nurse advised Ambien to help him sleep, but the medication never arrived. I don’t [do not] think I want that medication anyway; it may be too strong for my husband. His doctor is aware of it.”During an interview on August 6, 2026, at 1:30 PM, with the Director of Patient Care Services (DPCS), the DPCS stated, “It was the visiting nurse and case manager’s responsibility to update Medication Profile when there’s any new order or changes. Nurses should have been reviewing, updating medication profile on their visits and the printed MP should have been updated accordingly.”During a concurrent interview and record review on August 6, 2026, at 1:35 PM, with the DPCS, the agency’s policy and procedure (P&P) titled “Medication Profile,” dated April 2022, was reviewed. The P&P indicated, “ PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. …”. The DPCS stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to update the comprehensive assessment (a thorough and complete evaluation of a person) as frequently as the patient’s condition required to ensure the individualized Plan of Care (POC is a guide that lists the patient’s medical and emotional needs, including treatments, medications, and personal wishes to ensure comfort and care) addressed the patient’s changing pain and symptom management needs for one of five sampled patients (Patient 4), when the License Vocational Nurse (LVN) documented that Patient 4 was unresponsive (a patient does not react to verbal or physical stimuli and cannot communicate or follow commands, often indicating a significant change or deterioration in their medical condition), exhibited a significant change in condition, and appeared to be actively transitioning (a hospice patient is showing signs that they are approaching the end of life, and care is focused on keeping them comfortable during this time) on April 13, 2026,This failure had the potential to result in unrecognized or untreated pain and symptoms and delayed interventions during the patient’s transition toward the end of life, placing Patient 4 at risk for avoidable discomfort and reduced quality of life. Findings:A review of Patient 4’s face sheet (document that gives a summary of patient’s information) indicated, a start of care date of April 9, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of April 9, 2026, to April 14, 2026. Further review indicated Patient 4 had primary diagnoses that included Alzheimer disease (a type of dementia that causes problems with memory, thinking, and behavior, gradually worsening over time and interfering with daily life), pulmonary hypertension (high blood pressure in the arteries of the lungs that makes the heart work harder to pump blood through them, leading to shortness of breath and fatigue) and pulmonary fibrosis (condition where the lungs become scarred and stiff, making it harder to breathe and for oxygen to enter the bloodstream).During a concurrent interview and record review on August 6, 2026, at 11:30 AM, with the Director of Patient Care Services (DPCS), Patient 4’s “Visit Note LVN [License Vocational Nurse],” dated April 13, 2026, was reviewed. The “Visit Note LVN” indicated, “…Pain. Pain is in control? Yes. Pain level reported in this visit: 0 [zero for no pain] … SN [Skill Nurse] performed scheduled nursing visit. Patient found in bed, unresponsive to verbal and tactile stimuli... Patient exhibits mouth breathing and appears in active transition. Moderate shortness of breath and respiratory fatigue noted… SN requested an urgent RN [Registered Nurse] evaluation and recommended daily RN/LVN visits for transition management...” The DPCS verified and confirmed pain documentation.During a follow-up interview on August 6, 2026, at 11:35 AM, with the DPCS, the DPCS acknowledged that documenting a pain level of zero was inconsistent with Patient 4’s unresponsive condition, since Patient 4 was unable to verbally report pain. The DPCS stated that, according to agency policy, the visiting nurse should have used an appropriate observational pain assessment method to check the nonverbal patient for signs of pain, and the visiting nurse did not follow this procedure.During an interview on August 6, 2026, at 11:40 AM, with the DPCS, the DPCS stated that Patient 4’s change in condition and signs of active transitioning required a timely RN reassessment to identify the patient’s current pain, respiratory, and other symptom-management needs, which was crucial because its findings would provide the clinical information needed to update the POC with individualized interventions, medications, visit frequency, and monitoring instructions based on the patient’s current condition. The DPCS further stated that without the reassessment and POC update, staff might not have current instructions for managing Patient 4’s pain and symptoms during active transitioning. The DPCS confirmed that the clinical record did not contain evidence that the requested RN reassessment was completed to updated Patient 4’s POC to address Patient 4’s change in condition on April 13, 2026.During a concurrent interview and record review on August 6, 2026, at 11:45 AM, with the DPCS, the agency’s policy and procedure (P&P) titled, “PAIN ASSESSMENT”, dated April 2022, was reviewed. The P&P indicated, “PURPOSE. To provide guidelines for the appropriate identification and assessment of patients who may experience pain. POLICY. All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed … Pain assessments will be documented to facilitate regular reassessment and follow-up by clinicians. PROCEDURE. 1. During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data…3. If-the patient is unable to communicate pain using the rating scale is cognitively impaired or is a child the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment… 5. Pain assessments will be part of the comprehensive assessment and will be updated if significant changes occur…”. The DPCS stated the agency did not follow the policy.During a concurrent interview and record review on August 6, 2026, at 12:00 PM, with the DPCS, the agency’s P&P titled, “CARE OF THE DYING PATIENT”, dated April 2022, was reviewed. The P&P indicated, “PURPOSE. To provide guidance for the care of the dying patient… Procedure… 1. At the start of care and on an ongoing basis, hospice personnel will assess the patient and family/caregiver unit (when appropriate) for: A. Comfort/pain level and response to pain management… 3. With each patient visit, the hospice nurse will follow the plan of care and assess the need for change, update the plan of care, and document accordingly. Aspects of care that must be reflected in the clinical record, when applicable, include: A. The origin, location, severity (on a scale of 0- 10: 0=no pain, 10=unbearable pain), alleviating, and exacerbating factors for pain/discomfort …” The DPCS stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to develop an individualized Plan of Care (POC is a guide that lists the patient’s medical and emotional needs, including treatments, medications, and personal wishes to ensure comfort and care) or care plan that included interventions to manage pain and symptoms for one of five sampled patients (Patient 4), when Patient 4 was admitted to hospice services without a POC addressing the patient’s pain and symptom-management needs.This failure had the potential to result in Patient 4’s pain and symptoms remaining unrecognized or untreated and delayed interventions, placing Patient 4 at risk for avoidable discomfort and reduced quality of life. Findings:A review of Patient 4’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of April 9, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of April 9, 2026, to April 14, 2026. Further review indicated Patient 4 had primary diagnoses that included Alzheimer disease (a type of dementia that causes problems with memory, thinking, and behavior, gradually worsening over time and interfering with daily life), pulmonary hypertension (high blood pressure in the arteries of the lungs that makes the heart work harder to pump blood through them, leading to shortness of breath and fatigue) and pulmonary fibrosis (condition where the lungs become scarred and stiff, making it harder to breathe and for oxygen to enter the bloodstream).During a concurrent interview and record review on August 6, 2026, at 12:45 PM, with the Director of Patient Care Services (DPCS), Patient 4’s POC, dated April 9, 2026, was reviewed. There was no documented evidence to show Patient 4’s POC including individualized interventions designed to assess, monitor, and manage Patient 4’s pain were developed at the time of admission on April 9, 2026. The DPCS stated that he was unable to locate a pain care plan that should have been initiated upon admissionDuring an interview on August 6, 2026, at 12:50 PM, with the DPCS, the DPCS stated that the admitting RN was responsible for initiating an individualized care plan for each patient upon admission, including interventions to assess, monitor, and manage pain. The DPCS further stated that initiating patient’s pain care plan upon admission was crucial to provide staff with clear and consistent instructions for identifying and managing the patient’s pain.During a follow-up interview on August 6, 2026, at 1:15 PM, with the DPCS, the DPCS stated that he was the admitting RN for Patient 4 on April 4, 2026. The agency admission process is to initiate an individual care plan upon admission, including pain for management and intervention. The DPCS was unable to provide an explanation as to why and how the pain care plan for Patient 4 was missed, which should have been completed as part of the standard admission protocol.During a concurrent interview and record review on August 6, 2026, at 1:20 PM, with the DPCS, the agency’s policy and procedure (P&P) titled, “PAIN ASSESSMENT”, dated April 2022, was reviewed. The P&P indicated, “PURPOSE. To provide guidelines for the appropriate identification and assessment of patients who may experience pain. POLICY. All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed Pain assessments will be appropriate to the patient’s age, condition, ability to understand, and if the pain is acute or chronic. Pain assessments will be documented to facilitate regular reassessment and follow-up by clinicians. PROCEDURE. 1. During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data. Clinicians will consider the patient’s personal, cultural, spiritual, and ethnic beliefs when assessing pain or discomfort…”. The DPCS stated the agency did not follow the policy.During a concurrent interview and record review on August 6, 2026, at 1:25 PM, with the DPCS, the agency’s P&P titled, “The Plan of Care”, dated April 2022, was reviewed. The P&P indicated, “PURPOSE. To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY. A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program… PROCEDURE… 4. The plan of care will identify the patient’s needs and services to meet those needs including the management of pain and discomfort and symptom relief…”. The DPCS stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to follow its policy and procedure (P&P) to develop and maintain a system of communication and integration for one of five sampled patients (Patient 1), when Patient 1’s home clinical record did not contain the current Plan of Care (POC is a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care), while Patient 1 was receiving hospice care (a specialized type of end of lice care focused on comfort, dignity and quality of life). This failure had the potential to result in poor care coordination, unmanaged symptoms, and medication errors, which could place Patient 1’s safety, comfort, and overall well-being at risk in his end-of-life care. Findings:A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated, a start of care date of July 23, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of July 23, 2026, to October 10, 2026. Further review indicated Patient 1 had primary diagnoses that included malignant neoplasm of lower lobe, left bronchus or lung (a cancerous tumor growing in the lower part of the left lung or its airway)During a home visit on August 4, 2026, at 11:30 AM, with Medical Social Worker (MSW), in the presence of Patient 1 and Patient 1’s wife, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s most current POC including the MP (Medication Profile) were not found in the binder or anywhere in the house. Both MSW and Patient 1‘s wife confirmed that these essential documents were not available.During an interview on August 6, 2026, at 12:25 PM, with the Director of Patient Care Service (DPCS), the DPCS stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current POC and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the DPCS stated the current POC was crucial for maintaining effective care coordination, proper medication management, timely clinical responses and to facilitate continuity of care.During a concurrent interview and record review on August 6, 2026, at 12:35PM, with the DPCS, the agency’s P&P titled, “The Plan of Care”, dated April 2022, was reviewed. The P&P indicated, “PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY. A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program…PROCEDURE: 1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed… 4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs… 11… As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through…”. The DPCS stated the agency did not follow the policy.”