Every finding on record at Mid Valley Hospice Care, Inc.

Upon observation, there was no evidence the Emergency Plan communication plan must includes an alternate means for communicating with hospice's employees. The Emergency plan lists email only for the LVN, Medical Director, Spiritual Counselor and Volunteer Coordinator on staff log in the EPP plan for communication.

Upon patient record review, 1 of 5 (Patient #2) 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 equipment and supply needs. Patient #2: The record reflected that this patient had a walker and shower chair. These were not included on the plan of care.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The POC listed LVN visit frequency of, 2 X's per week. For Benefit Week 11/30/25 there was only 1 visit on 12/3/25 by the LVN.

Upon personnel record review, 1 of 12 (Personnel #8) 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.) ·Reading and recording rectal temperature. ·Toileting and elimination with bed pan. Personnel#8: The competency assessment for these tasks were completed as verbalized only.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record to be retained for seven (7) years according to Record Retention Policy No. 4-064.1. Agency did not retain previous medical records and were unable to maintain the patient's clinical record/clinical information in a confidential manner.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record to be retained for six years (CMS) and seven (7) years according to agency Record Retention Policy No. 4-064.1. Agency did not retain previous medical records. Agency had only 5 medical records for review.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the discharge summary includes all required information as follows: • The patient's current plan of care

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient and primary care giver receive education and training to their responsibilities for the care and services identified in the plan of care. For example: on review of HV#1 it was noted that the patient was an insulin dependent diabetic, however there was no documentation of education provided on diabetes management, hypo/hyperglycemia, blood glucose monitoring, and insulin administration nor was there indication that the patient/caregiver had shown proficiency in the tasks assigned. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, The individualized written plan of care did not reflect realistic time frames for the patient and family goals and interventions based on the problems identified in the comprehensive assessments. In review of the clinical records many of the target dates for the goals established were noted to not be individualized but set at the end of the benefit period or beyond. For example: in review of HV#1 goals for cardiac stated BP will be maintained between normal BP range: Systolic 95-145 and diastolic 70-90 as long as possible with medical interventions during hospice care and Prevent discomfort due to increased edema during hospice care and Family/PCG will verbalize/express understanding of medication/treatment orders and side effects during hospice care. In HV#3 there were goals such as patient verbalize understanding of 2-4 functional limitations as part of terminal condition and disease process by 6/30/23 (end of the benefit period). Further was a goal for nutrition that stated Patient will have adequate food and fluids as tolerated or desired for the next 3 months, Patient/family/PCG will verbalize understanding of at least 2 symptoms as part of the disease process and the limitations of treatment, with at target date of the end of the benefit period. Another example in RR#4 noted Patient will remain free of fall/injury by next IDG meeting and Family/PCG will verbalize understanding of 3 interventions to prevent falls and injury by (date of the end of the benefit period). These observations were reviewed with the Owner and Administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, 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. For example: on review of HV#1 the plan of care noted an order for Lantus 100 unit/ml give 30-32 units/ml subcutaneously at night. There was no indication as to when to give 30 units versus 31 or 32 units. In review of HV#2 there was documentation in the comprehensive assessment that the patient required thickener to fluids to a nectar consistency yet there was no physicians order for thickener, nor was it reflected in the plan of care. Further, the patient had an order to apply calmoseptine and A&D ointment to sacrum each diaper change, however the intervention on the care plan noted as cleanse with saline and cover with dry dressing in addition to the calmoseptine and A&D ointment. In review of HV#3 the nursing documentation noted edema to bilateral lower extremities with teaching of interventions to relieve, but the issue with edema was not reflected in the care plan. These observations were reviewed with the Owner/CEO and Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to ensure the patient record contain information that reflects the patient's care, treatment, and services. For example: on observation of medication reconciliation at HV#1, the patient caregiver noted that the patient was receiving Novolog insulin per sliding scale in addition to Lantus scheduled, however the Novolog was not listed on the clinical record's medication profile. This observation was reviewed with the Administrator/DPCS.