Valley Hospice Inc.

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; and Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the medication profile was updated with a full review of all medications that the patient was taking. Agency Policy: Medication Management in the Home (revised 10/28/2024), stated in part, “A medication profile is maintained as part of the medical record for all homecare patients and updated by the nurse at each visit or when medication changes occur.” CLINICAL RECORD 1: During the updated nursing assessment on 12/02/2024, the patient had increased problems with constipation and the senna was documented as increased to twice a day. The medication profile documented Senna as 1 time a day with as-needed doses but were not increased per the twice-a-day order. CLINICAL RECORD 3: The nursing assessment, dated 07/18/2024, documented the patient was using OTC (over-the-counter) pain cream for knee and arthritic pain. It was unclear what this cream was but the medication profile did not include this cream. The follow-up assessments documented that the cream was helping but there was no medication profile update and consequently no review of this treatment. CLINICAL RECORD 10: Admitted for GIP (general in-patient) care 01/31/2023 with medications morphine and Ativan administered through a PICC (peripherally inserted central catheter) line in the right arm. No saline or heparin was included on the medication profile which would be required between medications as well as for the PICC line maintenance. The medications were discontinued on 02/01/2024 but the PICC line was not discontinued and continued to require maintenance with saline and heparin. Joint record reviews were conducted with the Director of Compliance, who confirmed that these medication profiles had not been updated.”

“It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records reviewed, it was revealed that the agency did not ensure coordination of the plan of care by the registered nurse case manager to include interventions specific and appropriate for responsible disciplines and completion of wound documentation. CLINICAL RECORD 5: The Interventions documented 12/10/2024 on the plan of care included, “ Chaplain, dietician, physician, skilled, nurse social worker, volunteer to assess pain every visit every week, assess current medication schedule for side effects and to assess nutrition every week.” There was no dietician ordered or participating in the plan of care and the volunteer would not have participated in this assessment only provided companionship. CLINICAL RECORD 10: The initial plan of care was documented on 01/31/2024, and the initial comprehensive assessment identified a PICC (peripherally inserted central line) line in the arm that was being used and that a Foley catheter that was in place. The plan of care and updated plans did not include interventions for Foley care or care of the PICC line for monitoring and dressing changes that would be required. Skincare was identified but interventions were not documented to include wound care on the right buttock stage II, LLL (left lower leg) cellulitis with a dressing, Left buttock stage II with a dressing, and RLL (right lower leg) cellulitis with dressings. There was documented assessments of the Foley and PICC sites each nursing visit. CLINICAL RECORD 13: An intervention, documented 01/08/2025, on the plan of care included, “Pharmacist, skilled nurse Social worker, Spiritual care, volunteer to monitor medication regime.” This would not be appropriate for the social worker, chaplain, or volunteer to monitor. An OT (occupational therapist) was ordered on 11/11/2024 and evaluated on 11/12/2024 with a recommended frequency of 3 - 5 times a week with intervention and goals. The occupational therapist provided treatment for the right arm; however, the interdisciplinary conferences did not include the treatment or updates from the OT, who was part of the team. CLINICAL RECORD 15: An updated nursing assessment, dated11/25/2024, documented a wound assessment; location right breast, exudate appears serosanguinous; width, depth, and length were blank. The updated assessment on 12/30/2024 wound measurements were blank, and 01/06/2025 the measurements were blank. Updated assessment 11/25/2024 documented a dressing on the wound and each subsequent visit assessed the wound, reporting that the dressing was intact but the wound description and measurements were lacking. No wound infections were documented and improvement was noted but the detail of the wound was not documented. The supervisor stated, on 01//09/2025, that the wound documentation and details of interventions were not documented as they should have been by the case manager. During interviews with the Compliance Director and the Clinical Manager, conducted on 01/09/2024, they confirmed the findings.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 21 (38%) clinical records reviewed, it was revealed that the agency did not ensure that the plans of care documented all interventions for the care of the patients. Agency Policy: Interdisciplinary Team (revision date 03/22/2012) stated in part, “The plan of care will include identifying patient/family problems and needs.” CLINICAL RECORD 1: During the updated nursing assessment on 12/09/2024, a reddened coccyx was identified and measured at 2 cm x 0 cm. The updated plan of care, dated 12/24/2024, did not document any problems or interventions related to skincare or monitoring. Then the updated nursing assessment, dated 01/03/2025, documented redness around the stoma. As of the review on 01/07/2024, no interventions or problems related to skin integrity were documented on the plan of care. CLINICAL RECORD 3: The updated nursing assessment, dated 07/16/2024, included a Fall Risk Assessment with a score of 8 which continued with re-evaluations and statements of, “all chairs must have arms, or the patient will fall” but no interventions for fall prevention were documented on any of the updated plans of care. The updated nursing assessment, on 12/04/2024, documented wound care daily with triple antibiotic ointment on the right upper back and right hip but no skin integrity interventions were included on updated plans of care. The nursing assessment on 12/06/2024, documented aspiration precautions and the use of thickened fluids but the plan of care did not include any goals or interventions for this. CLINICAL RECORD 5: The plan of care included an intervention, dated 12/10/2024, that stated, “ Chaplain, dietician, physician, skilled nurse, social worker, and volunteer to assess pain every visit every week, assess current medication schedule for side effects and to assess nutrition every week.” There was no dietician participating on the case and these interventions are not appropriate for all disciplines assigned. CLINICAL RECORD 7: The initial comprehensive assessment, dated 01/17/2024, documented the patient was admitted with a Foley catheter, and an updated assessment on 01/21/2024 documented a wound with a dressing. The plan of care was not updated with interventions for skin integrity/wound or Foley catheter care before the patient death on 1/27/2024. CLINICAL RECORD 8: The initial comprehensive assessment was dated 01/19/2024 and documented the patient had end stage cardiac disease. An updated assessment, dated 01/22/2024, documented the patient had become imminent. The plan of care was not updated prior to death (on 02/01/2024) with any interventions for imminent death; the patient was using morphine daily with signs/symptoms of imminency. CLINICAL RECORD 10: The initial comprehensive assessment, dated 01/31/2024, identified a PICC (peripherally inserted central catheter) line in the right arm that was being used and documented that a Foley catheter was in place. The plan of care, effective on 01/31/2024, and updated plans did not include interventions for Foley care or care of the PICC line for monitoring and dressing changes that would be required. Per the nursing assessments there were wounds on the right buttock stage II, LLL (left lower leg) cellulitis with a dressing, Left buttock stage II with a dressing, and RLL (right lower leg) cellulitis with dressings. The plan of care did not include the wound care interventions. CLINICAL RECORD 20: The initial comprehensive was documented on 01/03/2025 and reported the patient was admitted with rectal CA (cancer) and had a Foley catheter in place. The updated assessment of 01/05/2025 documented a wound on the buttock, wound care was started and the wound was to be monitored. The initial plan of care, effective 01/03/2025 and the updated plans of care did not include the Foley catheter or skin integrity interventions. CLINICAL RECORD 21: The IPU (in-patient unit) initial comprehensive assessment, dated 01/05/2025, documented that a Foley catheter was in place. The plan of care, effective 01/05/2025 to current, did not include any interventions for the Foley catheter. Joint record reviews were completed with the Compliance Director who confirmed the findings, on 01/09/2025, and stated a performance improvement plan (PIP) was in place and the plans of care were being worked on.”

“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 the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed, of the community patients, the agency did not ensure that all medications and treatments were updated on the plan of care. Agency Policy: Interdisciplinary Team (revision date 03/22/2012) stated in part, “The plan of care will include: Identified patient/family problems and needs, Drugs and Treatments.” CLINICAL RECORD 1: During the updated nursing assessment on 12/02/2024, the patient reported increased problems with constipation and the Senna was documented as increased to twice a day. The medications on the updated plan of care, dated 12/24/2024, documented Senna as 1 time a day with as-needed doses but was not increased to reflect the two-times-a-day order. CLINICAL RECORD 10: The initial comprehensive assessment, dated 01/31/2024, documented a PICC (peripherally inserted central catheter) line in the right arm that was being used for medication administration. The PICC line would have required saline, and heparin flushes to maintain the line. The plan of care effective 01/31/2024 and updated plan of care did not include the saline or heparin flushes. During an interview, on 01/09/2025, with the Compliance Director who did a joint record review stated that the medications had not been correctly updated on the plans of care.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed, in which bereavement services were accepted, it was revealed that the agency did not ensure that bereavement services were provided in accordance with the plan of care. Agency Policy: Bereavement (revised date 02/21/2019) stated in part, “The bereavement counselor with the help of a volunteer will make scheduled contacts. Contact may be by phone or visit. A report of the contact/contacts will be kept in the patient’s chart in EMR (electronic medical record). All bereaved will receive mailings from hospice periodically throughout the year unless family refuses the mailing.” CLINICAL RECORD 6: The bereavement plan of care was documented on 01/12/2024 with ordered quarterly mailings. An Initial phone call was documented on 01/19/2024 to a friend who was bereaved. The documentation reported that the friend was low-risk and accepted mailings. As of the record review on 01/08/2025, the record lacked documented evidence that the mailings had been sent (this included the quarterly mailings for first quarter, second quarter, third quarter and fourth quarter for 2024). CLINICAL RECORD 7: The bereavement plan of care, dated 01/27/2024, included orders for follow-up phone calls in week 1 and week 6 and quarterly mailings. In week one, the phone call was documented as made. There was no documentation that the bereavement services were refused or declined. There was no documentation regarding the week 6 phone call, if it was made or not made. As of review 01/09/2025, the record lacked documented evidence that the mailings had been sent (this included the quarterly mailings for first quarter, second quarter, third quarter and fourth quarter for 2024). CLINICAL RECORD 8: The bereavement plan of care dated 02/01/2024, documented a low risk and included orders for phone calls in week 1 and week 6 and quarterly mailings. A volunteer documented that a call was made in week one, and to continue the plan for follow-up call week 6 and quarterly mailings. There was no documentation for the six-week call or of any of the mailings being sent. As of review 01/09/2025, the record lacked documented evidence that the mailings had been sent (this included the quarterly mailings for first quarter, second quarter, third quarter and fourth quarter for 2024). Joint record reviews were completed with the Compliance Director and the Bereavement Coordinator on 01/08/2025, the finding was confirmed that the Bereavement Coordinator stated that the volunteers sent the mailings but did not have a process of documenting this.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 8 of 15 (53%) clinical records reviewed, in which a hospice aide was accepted, the agency did not ensure that the Registered Nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 1: The aide plan of care, dated 12/9/2024, included the following relevant tasks; shower, skincare, peri-care, and apply barrier cream. The aide plan did not provide direction for when or where to apply the barrier cream. A nursing updated assessment, dated 12/09/2024, documented a reddened coccyx and a nursing assessment, dated 01/03/2025, documented stoma redness. The aide visit frequency was twice a week and the barrier cream application task was documented as completed each visit but did specify where the aide was applying the barrier cream. Furthermore, the aide plan did not provide documented directions for the stoma/ostomy that was present. CLINICAL RECORD 5: Documentation in the clinical record revealed the patient was forgetful, legally blind, and hard of hearing. The aide care plan, dated 10/17/2024, included orders for weekly visits with the assigned tasks; bed bath, shower, tub bath, and partial bath, dressing partial assist and independent. The aide plan was not updated until 11/19/2024 thus the aide was visiting weekly with no defined decision maker and no clear instructions for bathing and for dressing. CLINICAL RECORD 6: The aide plan of care, dated 01/8/2024, included the following relevant tasks: bed bath, shower, tub bath, partial dressing, and independent dressing. No decision-maker was identified for this confused patient. The aide plans were updated on 01/11/2024 to include ‘assist personal care of choice’ and ‘apply barrier cream’ as well as the same tasks as before. There was still no decision-maker identified and no further direction as to when the aide would perform the particular bathing or dressing or where or when to apply the barrier cream. CLINICAL RECORD 8: The aide plan of care was documented on 01/23/2024 with aide visits ordered weekly. Tasks ordered included: bed bath, shower, tub bath, and bath by self-personal choice - the patient was forgetful. Barrier cream was to be applied but no direction for where to apply it. Decubitus care was an assigned task but the patient had no decubitus. The aide plan was updated 6 times on 01/30/2024 with a bed bath every visit and barrier cream but continued with no direction for where to apply. Visits continued until death on 02/01/2024. CLINICAL RECORD 11: The aide plan of care, dated 10/11/2024, included the task of ‘apply barrier cream every visit’ but did not provide the aide directions for where to apply it. The aide did document it was applied at every visit but not where it was applied. CLINICAL RECORD 13: The aide plan of care, dated 10/14/2024, included tasks for bed bath, shower, and personal choice (however the record contained documentation that the patient was confused). The aide plan also ordered barrier cream to be applied, without specific instructions on location. The plan was updated on 11/25/2024 but still included “bath personal choice” and the barrier cream to be applied with no direction for where to apply. CLINICAL RECORD 14: The aide plan of care, dated 09/11/2024, included the task of decubitus care, there was no decubitus documented in the record until 12/05/2024 when a red coccyx was identified with instructions to keep open to air. The aide plan of care updates between 09/11/2024 and 12/05/2024 continued to include the decubitus care as a task even though there was not one present. Also, the aide plan of care, dated 09/11/2024, included barrier cream application as a task but no location for the application was documented. CLINICAL RECORD 15: The aide plan of care, dated 11/20/2024, included the tasks: assisting with a bed bath, assisting with a shower chair, and applying barrier cream. The aide plan did not provide clear direction for which bath or where or when to apply barrier cream. The Director of Compliance jointly reviewed the records on 01/09/2025 and stated that the software was new at the beginning of 2024 and confirmed that the plans were not documented with clear directions.”

“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 volunteer activity summary documented that the total amount of volunteer services provided in 2024 equaled 4.11% of the total patient care hours of all paid hospice employees and contract staff. In an interview with the Volunteer Coordinator on 01/08/2025, they agreed that the hours were below the required 5% and stated in part that they have had a difficult time recruiting and retaining volunteers since COVID-19. Document review: A 01/08/2025 review of the volunteer activity summary revealed that the agency did not ensure that 5% of services were provided by volunteers. Volunteer data from 2024 was reviewed indicating that 4.11% of total patient care hours was provided by volunteers for 2024. Interview with the Volunteer Coordinator on 01/08/2025, they agreed that the hours were below standard. She stated in part that they have had a difficult time recruiting and retaining volunteers since COVID-19. The discussion included some future considerations for recruitment. CMS L-647 CFR 418(e): Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that fire drills are held at least quarterly for each work shift. The facility utilizes 12-hour shifts. On 01/08/2025, a review of fire drill logs for years 2023 and 2024 revealed that fire drills were conducted on a monthly basis, but all drills with the exception of a drill conducted on 09/06/2023 were on the day shift. For the year 2023, no fire drills were conducted for the pm (6 pm - 6 am shift) for the first, second, or fourth quarter. For the year 2024, no fire drills were conducted for the evening shift 6 pm - 6 am) first, second, third, and fourth quarters. On 01/08/2025, interview with the hospice Facilities Manager indicated that drills have been primarily conducted on the day shift. He stated that he would be glad to conduct one drill a quarter on the night shift, and the other monthly drills on the day shift.”