Valley View Hospice & Palliative Care, LLC

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by personnel record review and interview. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure staff received initial training in emergency preparedness policies and procedures. Personnel Record 10: Volunteer dated of hire 10/25/2023. Personnel record review revealed no documented evidence of emergency preparedness training at the time of hire. During joint record review and interview on 01/30/2024, the Administrator and the Volunteer reviewed the finding and acknowledged that the volunteer record was missing emergency preparedness training at time of hire.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 8 (38%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 01/24/2024 with a diagnosis of malignant neoplasm of right breast with metastasis to central nervous system. The individualized plan of care dated 01/24/2024 included an activity of daily living goal that stated in part the patient would achieve “optimal independence.” The goal did not include a description of how “optimal independence” would be measured for the patient. Clinical Record 2: The patient elected the hospice benefit on 01/26/2024 with a diagnosis of malignant neoplasm of the upper lobe of the right bronchus/lung. The individualized plan of care dated 01/26/2024 included an activity of daily living goal that stated in part the patient would achieve “optimal independence.” The goal did not include a description of how “optimal independence” would be measured for the patient. Clinical Record 3: The patient elected the hospice benefit on 01/18/2024 with a diagnosis of congestive heart failure. The individualized plan of care dated 01/19/2024 included an activity of daily living goal that stated in part the patient would achieve “optimal independence.” The goal did not include a description of how “optimal independence” would be measured for the patient. During joint record review and interview on 01/30/2024, the Executive Director /Director of Patient Care Services /Alternate Administrator agreed that the identified plans of care goals were not measurable.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency was unable to provide evidence of volunteer hours for day to day administrative and/or direct patient care services provided. Review of the agency’s volunteer program/binder revealed hospice volunteer hours had yet to be logged for the agency. During a joint interview on 01/30/2024, the Administrator and Volunteer Coordinator stated that the agency has not yet needed to utilize a volunteer. After review of the standard the hospice acknowledged that the hospice is required to utilize volunteers to provide services that equals at least five percent of the total patient care hours, since the end of the public health emergency waiver beginning 01/01/2024. During an interview on 01/31/2024, the Administrator, the Volunteer Coordinator, and the Executive Director /Director of Patient Care Services /Alternate Administrator stated that the volunteer had performed 1 hour of service for the organization, but the agency was unable to provide the percentage of volunteer hours of the total patient care hours for all paid hospice employees and contract staff.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed, the agency did not ensure a complete hospice election statement was included in the record. Clinical Record 6: The patient elected the hospice benefit on 01/17/2024. Clinical record review revealed the hospice election of benefit statement did not include the effective date the patient elected the hospice benefit; the date was left blank but signed by the patient and clinician on 01/17/2024. During joint record review and interview on 01/30/2024, the Executive Director /Director of Patient Care Services /Alternate Administrator agreed that the hospice election statement was missing the effective date as required.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient transferred to a Medicare certified facility, the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility. Clinical Record 6: The patient elected the hospice benefit on 01/17/2024. The patient elected to revoke hospice care on 01/20/2024 and was transferred to the hospital for aggressive treatment. The clinical record contained no documented evidence that a discharge summary was forwarded to the receiving hospital. During joint record review and interview on 01/30/2024, the Executive Director /Director of Patient Care Services /Alternate Administrator confirmed the discharge summary had not yet been sent to the hospital.”