Every finding on record at Hospice Care of the Valley Inc

Based on interview and record review, the hospice agency failed to ensure the patient's home medication list was reconciled with the hospice agency medication list for one of 14 sampled patients (Patient 12).This failure had the potential for inappropriate dosing, miscommunication among caregivers, and decreased physical and psychosocial well-being for  Patient 12. --- During a home visit for Patient 12 on 12/16/25 at 10:30 a.m., the hospice agency home binder was reviewed. Medication list from the hospice agency was compared to the patient’s home medication list. An order for Benadryl (an antihistamine used to treat allergy, itching and cold symptoms) 25 mg by mouth every 6 hours as needed, for itching and allergy was missing from the patient's home medication list.   During an interview with the director of patient care services (DPCS) on 12/17/25 at 3:13 pm, the Director of Patient Care Services (DPCS), The DPCS acknowledged that the Benadryl was not listed on the home medication list. During a review the facility policy and procedure (P&P) titled “Medication Reconciliation,” dated 12/2/08, the P&P indicated in part “Medication reconciliation consist of a comparison of those medications ordered for, administered to, or dispensed to the patient while under the care of the organization to those on the list and any discrepancies are resolved.”

Based on interview and record review, the agency failed to ensure 14 of 14 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14), had their drug profile (a review of all prescribed and over the counter medications taken by the patient) recorded in their medical record and a copy of the teaching provided to the patient or their family. This failure resulted in undocumented drug therapy teaching for the patient and/or their families and no written information for them to refer to. --- Findings: During a review of the facilitys policy and procedure (P&P) titled, ";Medication Profile/Investigational Drug Policy," dated 1/15/05, the P&P indicated, ";The nurse responsible for the initial comprehensive assessment will complete the medication profile ordered by the attending physician during the admission process... Identify the individual(s) authorized to administer each medication and provide patient/family/caregiver education as it relates to the administration, patient response and side effects." During a concurrent interview and record review on 9/7/23 at 11:50 a.m. with a Registered Nurse Case Manager (RNCM2), Patient 3s ";Comprehensive Nursing Assessment" (CNA), dated 5/13/23 was reviewed. The CNA indicated, ";Teaching needs... Teach Patient/Family/PCG [primary caregiver] ... Medications (Administration side effects/contraindications, comfort pak, use & risk opiods [pain medicine], Rx [prescription] services)." RNCM2 stated, ";Usually when I document, I put a statement that the medications were reviewed." During a concurrent interview and document review on 9/7/23 at 12:05 p.m. with the Administrator/Director of Patient Care Services (Adm/DPCS), the agencys ";Drug Therapy Teaching Form" (DTTF), undated, was reviewed. Adm/DPCS stated the agency stopped using this form about five years ago when they switched from paper charting to electronic charting. Adm/DPCS further stated no current patient had received a copy of the form or had it placed in their medical record.

Based on interview and record review, the agency failed to ensure three of 14 sampled patients (Patient 2, 3, and 14), had complete and accurate documentation in their medical record when: 1. Patient 2s ";Physicians Certification for Hospice Benefit" ((PCHB) physician certifying the patient is terminally ill with a life expectancy of 6 months or less should the disease run its normal course) indicated the certification was based on a ";Face to Face Encounter" in error. 2. Patient 3s ";POC [Plan of Care]/IDG [Interdisciplinary Group] Review"((POC/IGD) a plan made by a group of healthcare professionals to address the identified and potential health needs and risks of the patient) indicated ";Declines hospice aide" in error. 3. Patient 14s medical record did not contain documentation of the Hospice Aides visits on 6/18/23, 6/22/23, and 6/25/23. These failures had the potential to result in a decreased quality of care (healthcare services that are safe, effective, patient-centered, timely, and efficient). --- 3. During a review of the Resident 14s Face Sheet, dated 6/16/22, the Face Sheet indicated, Resident 14 had a Start of Care (SOC) on 6/16/22 and a primary diagnosis of Alzheimers disease, unspecified. During a review of the Resident 14s History and Physical (H&P), dated 6/16/22, the H&P indicated, Resident 14 was an 85-years old with diagnosis of Alzheimers dementia (inability to remember, think, or make decisions that interferes with everyday activities) and was hospice appropriate. During a review of Resident 14s Hospice Certification of Terminal Illness (CTI), dated 6/16/22 to 8/14/22, the CTI indicated, Resident 14 had to be seen by a Hospice Aide (HA) two times a week. During a review of Resident 14s Physicians Order, dated 6/16/22, the Physicians Order indicated, ";Hospice Aide to visit 2x/week (two times a week) and as needed." During a review of Resident 14s monthly calendar for June 2022, the calendar indicated, HA visit was scheduled on 6/18/22, 6/22/2022, and 6/25/22. During a review of Resident 14s Flow Sheet (a form used for documentation), dated 6/17/22 to 6/28/22, no HA documentation was found. During an interview on 9/8/23, at 2:00 p.m., with the Registered Nurse Case Manager (RNCM 1), the RNCM 1 stated, the HA must document for each visit. The RNCM 1 further stated and verified, the HA had no documentation on 6/18/22, 6/22/2022, and 6/25/22 visits. According to Fundamentals of Nursing (Potter et al.; Elsevier: 2017, p. 356), "A patients medical record is a valuable source of data for all members of the health care team. Data entered into the medical record facilitate interdisciplinary communication; provide a legal record of care provided; justify financial billing/reimbursement; and allow for auditing, monitoring, and evaluation of care provided." During a review of the facilitys policy and procedure (P&P) titled ";Medical Records," dated 12/2/08, the P&P indicated, ";Maintain for each patient a health record that shall consist of at least the following... A concise and accurate record of care and treatment administered." 1. Patient 2 is an 81-year-old male admitted to hospice on 6/15/23 with a primary diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills) and comorbidities (additional medical conditions and risk factors) leading to a steady decline in health, appetite, and an increase in fatigue. During a concurrent interview and record review on 9/6/23 at 11:30 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2s PCHB, dated 6/15/23 was reviewed. The PCHB indicated, ";Verbal Authorization Date: 6/15/23 Obtained by... Certification is based on... Face to Face Encounter." ADM/DPCS stated, ";It was marked in error." ADM/DPCS further stated the Certification was based on medical history, record, and patient status report to the Medical Director by phone. 2. Patient 3 is an 88-year-old female admitted to hospice on 5/13/23 with a primary diagnosis of Alzheimers disease and comorbidities leading to a steady decline in health, appetite, and increasing weakness. During a concurrent interview and record review on 9/7/23 at 12:30 p.m. with a Registered Nurse Case Manager (RNCM2) Patient 3s POC/IGD, dated 5/23/23 was reviewed. The POC/IGD indicated, "Declines hospice aide." RNCM2 stated, ";It was an error." RNCM2 further stated the patient had a Physicians Order for a hospice aide to visit twice a week.