Every finding on record at Comprehensive Valley Hospice Care Inc

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: The Election Statement did not include name of the hospice in space provided on the form. The Attending Physician choice filled in on the form could not be verified with an associated hospice.

Upon patient record review, 3 of 14 (Patients #1,2,3) 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: During medication reconciliation there was no Amlodipine Besylate 10 mg in the home as indicated on hospice medication profile. RN to follow-up with physician as other BP med types are in the home. Patient #2: During medication reconciliation there was no Docusate Sodium 10mg/mL (5mL ordered) BID in the home as indicated on hospice medication profile. Additionally, the following meds were in the home but not included on hospice medication profile. They were Omeprazole 40mg (4/8/25 fill date), Amlodipine 10mg (5/29/25 fill date), Clonidine 0.1mg (5/29/25 fill date) and Calcium 500mg chew tabs (5/29/25 fill date). Patient #3: During medication reconciliation there were additional medications in the home that were not on hospice medication profile. They were Ondansetron 1mg (no identified fill date), Nystatin powder (6/2/25 fill date) and Voquezna 10mg (OTC med)

Upon patient record review, 2 of 14 (Patient #2,3) 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: The following meds were in the home but not included on the hospice plan of care. They were Omeprazole 40mg (4/8/25 fill date), Amlodipine 10mg (5/29/25 fill date), Clonidine 0.1mg (5/29/25 fill date) and Calcium 500mg chew tabs (5/29/25 fill date). Patient #3: During medication reconciliation there were additional medications in the home that were not on the hospice plan of care. They were Ondansetron 1mg (no identified fill date), Nystatin powder (6/2/25 fill date) and Voquezna 10mg (OTC med).

Upon personnel record review, 1 of 11 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7: The Initial Aide Competency did not include observed tasks (verbal only) for the following skills: • Reading and recording temperature (auxiliary, digital, rectal) • Safe transfer techniques and ambulation (chair to standing).

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 Agency is tracking hours in Hospice MD, EMR that is approx. 655 hours in 12 months. However, The EMR is not tabulating hours to a dollar amount of cost savings for use of volunteers.

Upon personnel record review, 2 of 11 (Personnel #10, 11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Corrected on site- orientation updated during survey.

Upon personnel record review, 2 of 11 (Personnel #10, 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #10: The Volunteer Coordinator did not have an Initial Skills Competency in their file. Corrected on site- Competency completed during survey. Personnel #11: The Volunteer did not have an Initial Skills Competency in their file. Corrected on site- Competency completed during survey.

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The Election Statement did not include Name of the Hospice in space provided on the form.

Upon patient record review, 1 of 14 (Patient #1) 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: Consents did not have hospice name filled in space provided on the form.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information as follows: • The patient's current plan of care

Upon personnel record review, 2 of 11 (Personnel #10, 11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #10, 11: Did not have criminal background check in employee file. Corrected on site background check updated 7/11/25

Upon patient record review, 1 of 1 applicable (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #3 The 1/7/22 aide assignment did not contain frequencies for the following tasks; change linens, nail care, mouth care, hair care, and shower.