Every finding on record at Sun Valley Hospice Inc

Upon patient record review, 1 of 14 (Patient #9) 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 #9 - The medication profile showed Tylenol 500mg with directions to take two caplets prn for pain. There was no frequency listed for this medication

Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5 - Patient was admitted on 08/20/25. The initial bereavement risk assessment was not completed until 09/25/25. There was no evidence that the elements of the initial bereavement assessment were assessed prior to that date. The bereavement assessment dated 09/25/25, did not include the elements of the initial bereavement assessment to include the specific or primary bereaved. There was documentation that spoke about how to incorporate spiritual aspects into their daily routine, without assessing the mental health, social or environmental components required in the bereavement assessment

Upon patient record review, 8 of 14 (Patient #2,3,4,6,8,9,13,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2, 3, 4, 13, 14 - The advanced directives showed patient wished to remain a full code. The plan of care did not contain problems, goals, or interventions related to the full code status. Patient #6 - The patient medical record shows an order for a mechanical soft diet. There was no problems, goals or interventions listed related to dysphagia. Patient #8 - The advanced directives showed patient wished to remain a full code. The plan of care did not contain problems, goals, or interventions related to the full code status. The patient is also on a mechanical soft diet. There was no problems, goals or interventions listed related to dysphagia. Patient #9 - The advanced directives showed patient wished to remain a full code. The plan of care did not contain problems, goals, or interventions related to the full code status. The medication profile listed the patient is on methotrexate for his cancer. There was no problems, goals, or interventions related to this treatment.

Upon patient record review, 3 of 14 (Patient #2,4,9) 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 medical record showed an order dated 10/23/25 indicating patient is a DNR. The POLST form in the record dated the same day, listed patient as a full code, with the patient's signature and initials on this form. Patient #4 - The comprehensive nursing assessment dated 10/15/25, documented patient diet as a low lipid, low carbohydrate diet. There was no evidence of an order for this diet. Patient #9 - The medical record contained an order dated 07/03/25 for Tylenol 500 mg with instructions to take 2 caplets prn for pain. There was no frequency listed for that medication.

Upon patient record review, 3 of 14 (Patient #3,4,9) 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 #3 - The nursing comprehensive dated 10/22/25, listed patient to be incontinent of bowel and bladder. There was no evidence of incontinent supplies on patient's plan of care. Patient #4 - The nursing comprehensive dated 10/15/25, listed patient to be incontinent of bowel and bladder. There was no evidence of incontinent supplies on patient's plan of care. Patient #9 - The medication profile listed Duoneb to be given via nebulizer. There was no evidence of a nebulizer listed as a DME item in the patient's plan of care.

Upon patient record review, 9 of 14 (Patient #1,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - Patient medical record showed the MSW comprehensive assessment dated 10/25/25 and subsequent visit dated 11/24/25, were documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #3 - Patient medical record showed the MSW comprehensive assessment dated 10/23/25 and subsequent visit dated 11/21/25, were documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #4 - Patient medical record showed the MSW comprehensive assessment dated 10/16/25 and subsequent visit dated 11/14/25, were documented as telehealth visit in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #5 - Patient medical record showed the MSW comprehensive assessment dated 08/22/25 and subsequent visit dated 09/22/25, 10/21/25, and 11/18/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #6 - Patient medical record showed the MSW comprehensive assessment dated 08/16/25 and subsequent visit dated 09/15/25, 10/14/25, and 11/12/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #7 - Patient medical record showed the MSW comprehensive assessment dated 08/14/25 and subsequent visit dated 09/16/25, 10/15/25, and 11/11/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #8 - Patient medical record showed the MSW comprehensive assessment dated 07/05/25 and subsequent visit dated 08/03/25, 09/02/25, 10/02/25 and 11/01/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #9 - Patient medical record showed the MSW comprehensive assessment dated 07/04/25 and subsequent visit dated 08/01/25, 09/01/25, 10/28/25, and 11/26/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits. Patient #10 - Patient medical record showed the MSW comprehensive assessment dated 04/21/25 and subsequent visit dated 05/24/25, 06/23/25, 07/24/25, 08/23/25, 09/23/25, 10/22/25, and 11/23/25 were all documented as telehealth visits in the narrative section of those notes. The visits are ordered as one visit per month and one prn. There was no evidence of any other visits completed by the MSW. There was no documentation of consent or an order for telehealth visits. In addition, telehealth can not replace in person visits.

Upon patient record review 1 of 14 (Patient #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #11 - The medical record showed an order for aide visits starting on 04/16/25 for two times per week. The aide plan of care also showed these same frequencies. There was no evidence that the aide visits occurred.