Every finding on record at Greater Valley Hospice Alliance LP

Observed in Record Review. In 1 of 4 patient records reviewed, the plan of care (POC) did not include all medications and treatments necessary to meet the patient's needs. In the chart for RRNHV#3, the POC included an incomplete medication order, Compounded medication to be administered 1ml every 4 hours prn anxiety to the patient's wrists. The SN notes indicated this was ABH gel. This was discussed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge for extended prognosis, the organization failed to respect the patient's right to participate in decisions about their care, treatment, or services. In RRDC#2 the patient was discharged for extended prognosis yet there was no Notice of Medicare Non-Coverage form located on the patient record. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 active records reviewed, the organization failed to ensure the patient specific comprehensive assessment and reassessment identified the patient's need for hospice care and services. On review of RRHV#10 the skilled nurses documentation noted that the patient answered yes to are you uncomfortable because of pain yet there was no pain assessment documented. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 active patient records, the organization failed to ensure complete and accurate patient records. On review of RRNHV#6 the documentation noted LVN supervisory visit throughout the 2nd benefit period yet there were no LVN visits documented during that time period. Further, the plan of care noted a goals that stated patient constipation is controlled related to opioid use however the patient was not prescribed opioid medication. This observation was reviewed with the Administrator. Observed in Record Review. In 1 of 14 active patient records reviewed, there were inaccuracies. In patient record RRHV#1 a nurse repeatedly documented that the patient was eating 8 to 12 ounces of food three times a day. However, MAC measurements indicated significant weight loss and gain as they fluctuated between 21 and 29 cms in 15 cms. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing.

Observed in Record Review. In 7 of 14 patient records reviewed, most plan of care goals were not individualized or measurable. Here are some examples. Patient will tolerate ADLs within constraints of disease. Patient will tolerate assessment of sensory/neurological status. Patient/caregiver verbalizes understanding of decreased appetite and cachexia in the dying process. Patient is in control of what, how much and when to eat. Patient will maintain stable condition during episode of care enabling them to receive care at home. Patient will verbalize comfort with respiratory disease process allows. Patient will have diminished incident of cough. Patient will verbalize decrease in pain or have decrease in non-verbal signs and symptoms of pain as a result of pharmacologic pain control. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing. Observed in Record Review. In 7 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were individualized, specific, measurable, and time-bound. In review of all active records it was noted that goals were not specific, measurable, or time-bound. An example from RRHV#3 was Patient will verbalize comfort with respiratory status as disease process allows and an example for RRHV#4 was Patient verbalizes adequate pain control as a result of pain control reached prior to reaching an unmanageable level. In RRNHV#6 an example was Patient/caregiver will have decrease in edema within constraints of disease. In RRNHV#7 a goal read Patient exhibits return demonstration of disease management techniques and RRNHV#8 a goal read Patient’s nonskilled care needs are achieved safely. Similar observations could be viewed in RRNHV#9, and RRNHV#10. These observations were reviewed with the Administrator.

Observed in Record Review. In 6 of 14 active patient records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 the documentation noted multiple UTI's and URI's yet there was no care plans opened to guide the care of the infection. On review of RRHV#4 the documentation noted the patient with increasing constipation requiring the addition of Lactulose yet the issue was not reflected in the plan of care. In RRNHV#6 there was documentation of a cough, and edema to the lower leg yet there was no reflection of the issues in the plan of care. In RRNHV#7 the patient was being seen by the chaplain yet there was no spiritual care plan to guide the care. In RRNHV#8 there was documentation of two UTI's, a wound, and debrox ordered for an ear issue yet there were not reflection of the issues in the care plans. In RRNHV#9 there was documentation of UTI's, a skin infection and a wound yet the issues were no care plans to guide the care specific to the issue. These observations were reviewed with the Administrator.

Observed in Record Review. In 7 of 14 active patient records reviewed, the organization did not ensure that the comprehensive assessment was updated no less than every 15 days. For example, in interdisciplinary group meeting notes written by core team members patient decline, progress towards desired outcomes and goals, and plans for the following two weeks were not addressed in patient records RRHV#1, RRHV#2, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing. Observed in Record Review. In 6 of 14 active patient records reviewed, the organization did not ensure that the plan of care reflected problems identified in clinical assessments and re-assessments. In patient records RRHV#1, RRHV#2, RRNHV#1, RRNHV#2, RRNHV#4, and RRNHV#5 the MAHC - 10 score indicated that the patient was at a high risk for falls but was not addressed in the plan of care. In patient record RRHV#1 a nurse documented that the patient had fallen several times in the 32 months he was receiving hospice services, however the plan of care was not revised accordingly. And in patient record RRNHV#2 one of the goals was that the patient would not infect others while he had COVID-19. According to the DON for that area, the patient did not have COVID-19 while receiving hospice care. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing.

Observed in Record Review. In 1 of 14 active patient records reviewed, the plan of care was incomplete. In patient record RRNHV#3 there were orders for Hydrocodone and Morphine as needed for pain but there were no instructions for what drug to use for what level of pain. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing. Observed in Record Review. In 1 of 14 active patient records reviewed, the plan of care was incomplete. In patient record RRNHV#5 a nurse documented in the initial comprehensive assessment that the patient had a peg tube. An order for Glucerna did not include volume, rate, and frequency. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing. Observed in Record Review. In 4 of 14 active patient records, the organization failed to ensure the plan of care include all medications and treatments necessary to meet the patients needs. On review of RRHV#4 the documentation noted the patient was started on Lactulose for constipation yet there was no physicians order for the medication. In RRNHV#7 there were orders for multiple pain medications of Tylenol 500mg and Tylenol 325 MG as needed, along with Tramadol, and Morphine yet there was no specific instructions to guide the user as to which medication and dosage to choose for what type of pain and when. Further, there was no guidance as to what dosage of acetaminophen not to exceed. In RRNHV#9 there was an incomplete wound order that stated cleanse area with wound cleanser, pat dry with gauze, apply iodine liquid with cotton tip applicator to affected area, leave open to air The order did not specify a location, frequency, nor who was to perform the care. In RRNHV#10 there was an order for oxygen 5-10 lts per minute continuous but no specific instructions on how to adjust the oxygen. Further, there was an additional duplicate order that specified oxygen at 7 lts per minute continuous. These observations were reviewed with the Administrator.

Observed in Record Review. In 7 of 14 active patient records, the organization failed to review, revise and document the individualized plan as frequently as the patient condition requires but no less frequently that every 15 calendar days. Throughout the records reviewed there was a noted lack of update to the plan of care as the goals and interventions were established at start of care and remained unchanged without documentation of progress to goals and updates related to changes in patient condition from IDG to IDG from admission to time of survey. In RRHV#3 goals were established in 2023 and remained unchanged to date. IDG meeting documentation noted plan of care reviewed yet no changes based on the comprehensive assessment was noted in the record. These observations were reviewed with the Administrator. Observed in Record Review. In 7 of 14 active patient records reviewed, the organization did not ensure that the comprehensive assessment was updated no less than every 15 days. For example, in interdisciplinary group meeting notes written by core team members patient decline, progress towards desired outcomes and goals, and plans for the following two weeks were not addressed in patient records RRHV#1, RRHV#2, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the RN prepare written patient care instructions for the hospice aide. On review of RRHV#3 the patient was prescribed Eliquis yet there were no bleeding precautions noted on the aide plan of care. In RRHV#4 the patient had a wound with wound treatments yet the aide plan of care did not include specific instruction on how the aide should handle the wound while providing care. In RRNHV#9 the patient had wounds with wound care treatment yet there were no instructions for how the aide was to handle the areas while providing care. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the hospice aide was supervised effectively. On review of RRHV#3 the RN failed to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days as the last documented aide supervisory visit was in February. In RRHV#4 there was a 28 day gap in documented aide supervisory visits from January to February, and a 41 day gap from Feb to March. These observations were reviewed with the Administrator.

Observed in Tracer Activities. During a review of the volunteer program and discussion of the program structure with the volunteer cordinator, the Hospice Pharmacy Surveyor noted that while the organization stated that they had tried to recruit and retain volunteers, there was no documentation to support this statement. The organization had 8 hospice locations with only five ongoing current volunteers total for these locations and all of these were social work students volunteering to complete a course requirement for their degree and were leaving when the requirement was satisfied, per the volunteer coordinator. This omission was validated at the time of the survey with the volunteer cordinator and other hospice management staff.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 2 of 14 active patient records reviewed, the certificate of terminal illness did not include subjective and objective information to support patient life expectancy of six months or less. In patient records RRHV#1 and RRHV#2 the documents lacked metrics or decline related to the terminal diagnosis. This RFI was reviewed with and verified by the Regional Clinical Director and the Area Director of Nursing.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure the hospice discharge summary was provided to the patient's attending physician. On review of RRDC#1 there was no documentation of the discharge summary being sent to the attending physician. This observation was reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 2 and HV# 3's home observation it was noted the organization had not ensured the patient record was accurate. For example: during the home observations of HV# 2 and HV# 3, it was noted the patients were receiving oxygen. During the home observation it was noted both homes had gas stove tops. Review of the HV# 2 and HV# 3's patient records revealed an oxygen safety risk assessment with documentation that there were no possible open flames in the home. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV# 2's patient record review it was noted the organization had not ensured the plan of care was updated. For example: review of HV# 2's patient record revealed a wound to the left heel and wound care orders. Further review of the patient record revealed the wound had resolved in the skilled nurse visit note dated 36 days prior to the surveyor review of the record. Review of the three updates to plan of care/Interdisciplinary Group (IDG) revealed wound care interventions and wound care dressing change orders on the medication list. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in HR File Review. In 2 of 2 physician HR files reviewed, During HR# 12 and HR# 13's HR records review, it was noted the organization had not ensured the contracted Medical Director and alternate Medical Director had their competence assessed and documented once every three years in accordance with law and regulation. This was reviewed, discussed, and validate by the Administrator.