Every finding on record at Kittitas Valley Home Health & Hospice

. Based on document review, record reviews, and interview, the agency failed to follow the ordered frequency of services necessary to meet the patients’ and families’ needs for 2 of 3 patients receiving Hospice Aide services (Patient #101 and #111).Failure to follow the plan of care, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. --- Findings included: 1. Document review of agency's policy titled, "Scope of Services Hospice," (Policy ID: 11503, Last revised: 09/05/24) showed the frequencies of services provided by the agency are in accordance with the patient’s plan of care and needs as assessed and identified by the agency’s interdisciplinary team.  2. Record reviews for 2 of 3 patients receiving Hospice Aide (HA) services (Patient #101 and #111) showed:   a. Patient #101 was admitted on 11/09/24 with diagnosis a primary diagnosis of Alzheimer’s and Dementia.On 11/10/24, the physician ordered HA services 2 times per week for 12 weeks. The weeks of 11/10/24 and 01/12/25, the patient received only 1 of 2 HA visits. There was no documentation as to why there were missed HA visits, nor was there documentation that the physician had been notified of the missed HA visits.b. Patient #111 was admitted on 12/28/24 with a primary diagnosis of Alzheimer’s and Dementia. On 12/29/24, the physician ordered HA services 2 times per week for 13 weeks. The weeks of 01/05/25, 01/12/25, and 01/19/25 the patient only received 1 of 2 HA visits. The week of 02/16/25 there were no HA visits made. There was no documentation as to why there were missed HA visits, nor was there documentation that the physician had been notified of the missed HA visits. 3. On 04/29/25 at 3:00 PM, the Surveyor interviewed the agency's Chief Ancillary Officer (Staff #113) on the lack of documentation and notification to the physician of the HA missed visits. Staff #113 acknowledged the findings and stated that they were unable to provide documentation of why the missed HA services occurred and why the patients' physicians were not notified. .

. Based on document review, record reviews, and interview, the agency failed to ensure the hospice aide (HA) competencies were completed for 1 of 2 hospice aides (Staff #105).Failure to complete the hospice aide competencies place patients at risk of receiving care from unvetted caregivers. --- Findings included: 1. Document review of agency's policy titled, "Competency Testing, Home Health/Hospice Aide," (Policy ID: 11390, Last revised: 06/24/24) showed the agency shall follow the hospice aide competencies mandated by the Conditions of participation for Home Health/Hospice and documentation of hospice aide competencies will be maintained in Staff development.2. On 04/29/25 at 11:00 AM, a record review of Staff #105 personnel records showed Staff #105 was hired on 07/08/24, and the following HA competency items were missing from their records: a.      Communication skills, including the ability to read, write, and verbally report clinical information to patients, care givers, and other hospice staff. b.     Observation, reporting, and documentation of patient status and the care or service furnished. c.      Reading and recording temperature, pulse, and respiration. d.     Basic infection control procedures. e.      Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. f.        Maintenance of a clean, safe, and healthy environment. g.      Recognizing emergencies and the knowledge of emergency procedures and their application. h.     The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property. i.        Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist:         i.       Bed bath; (B) Sponge, tub, and shower bath;                  ii.       Hair shampoo (sink, tub, and bed);        iii.       Nail and skin care;        iv.      Oral hygiene;v.      Toileting and elimination; j.        Safe transfer techniques and ambulation. k.     Normal range of motion and positioning. l.        Adequate nutrition and fluid intake.. 3. On 04/30/25 at 9:00 AM, the Surveyor interviewed the agency’s Chief Ancillary Officer (Staff #113) about the lack of documentation of Staff #105’s HA competency items.  Staff #113 acknowledged the findings and stated that they were not able to provide any documentation on Staff #105’s HA competencies. .

. Based on document review, record reviews, and interview, the agency failed to conduct Hospice aide supervisory visits by a Registered Nurse (RN) at least every 14 days for 1 of 3 patients receiving Hospice Aide services (Patient #111).Failure to supervise the hospice aides at least every 14 days places the patient at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. --- Finding included:1. Document review of the agency’s policy titled, “HHH Aide Services and Supervision,” (Policy No. 11489, Last revised: 06/24/24) showed the RN will make an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services provided by the aide are meeting the patient’s needs.  2. Record review for 1 of 3 patient receiving Hospice Aide services (Patient #111) showed:a. Patient #111 was admitted on 12/28/24 with a primary diagnosis of Alzheimer’s and Dementia. The Physician ordered HA services 2 times per week for 13 weeks starting on 12/29/24. There was no documentation of RN supervisory visits for the periods of 02/09/25-02/22/25 (2 weeks), 02/23/25-03/08/25 (2 weeks), and 03/09/25-03/22/25 (2 weeks).3. On 04/29/25 at 3:30 PM, the Surveyor interviewed the agency’s Chief Ancillary Officer (Staff #113) about the lack of supervisory visits on Hospice Aides by the RN at least every 14 days. Staff #113 acknowledged the findings and stated that they were not able to provide any documentation on the missing supervisory visits.

Based on record review and interview, the agency staff failed to complete the initial bereavement risk assessment as part of the initial comprehensive assessment for 4 of 11 patients (Patient #201, #203, #204, and #208). This failure has the potential to delay or overlook the needs of the patient's family and others in their ability to cope with the patient's death. Findings included: 1. Document review of agency's policy titled, "Hospice Admission Process," (Last reviewed 04/08/2022) showed that a bereavement assessment will be included in the comprehensive assessment. 2. Record review of the charts for 4 patients (Patient #201, #203, #204, and #208) showed: a. Patient #201 was admitted on 12/03/2021. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. b. Patient #203 was admitted on 12/12/2021. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. c. Patient #204 was admitted on 11/30/2021. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. d. Patient #208 was admitted on 03/10/2022. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. 3. Surveyor #2 interviewed the Hospice Clinical Manager (Staff #202) on 05/04/22 at 9:00 AM about the lack of initial bereavement assessments. Staff #202 acknowledged the missing initial bereavement assessments