Every finding on record at Valeo Hospice LLC

Based on interview and record review, it was determined the hospice agency did not ensure the interdisciplinary group, in consultation with the individual's attending physician, completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Specifically, spiritual counselor (SC) and social worker (SW) involvement in the comprehensive assessment was either late or could not be found for 6 of 19 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 3, 5, 8, 9 and 13) --- Findings include: 1. Patient 1 was admitted to the agency on 7/12/23, with a terminal diagnosis of Alzheimers. A review of patient 1's medical record was completed on 8/14/23. According to documentation in patient 1's medical record, the SW did not complete an initial assessment until 7/20/23, 9 days after patient 1s start of care (SOC). The SC did not complete an initial assessment until 8/9/23, 29 days after patient 1s SOC. 2. Patient 3 was admitted to the agency on 7/2/23, with a terminal diagnosis of renal cell carcinoma. A review of patient 3's medical record was completed on 8/14/23. According to documentation in patient 3's medical record, the SC did not complete an initial assessment until 7/17/23, 16 days after patient 3s SOC. 3. Patient 5 was admitted to the agency on 7/1/23 with a terminal diagnosis of Alzheimer's disease. A review of patient 5's medical record was completed on 8/14/23. According to documentation in patient 5's medical record, the SW did not complete an initial assessment until 7/25/23, 25 days after patient 5s SOC. The SC did not complete an initial assessment until 7/17/23, 12 days after patient 5s SOC. 4. Patient 9 was admitted to the agency on 7/19/2023, with a terminal diagnosis of heart failure unspecified. A review of patient 9s medical record was completed on 8/14/23. According to documentation in patient 9s medical record, the SC did not complete an initial assessment until 7/31/2023, 12 days after patient 9s start of care. No documented evidence of SW involvement in patient 9's comprehensive assessment could be found in his medical record. In an email received from the administrator on August 10, 2023, at 10:28 AM. She stated, ";per report from the MSW (master of social work) and Chaplin (SC), family postponed both assessments. Per supervisor SW and SC, have since been trained to complete missed visit documentation and to explain why assessments were not completed within the first 5 days of care." 5. Patient 13 was admitted to the agency on 6/15/23 with a terminal diagnosis of neoplasm of thyroid gland. A review of patient 13's medical record was completed on 8/14/23. According to documentation in patient 13's medical record, the SC did not complete an initial assessment until 6/21/23, 7 days after patient 13s SOC. No documented evidence of SW involvement in patient 13's comprehensive assessment could be found in her medical record. 6. Patient 8 was admitted to the agency on 6/14/23, with a terminal diagnosis of Cholangiocarcinoma. A review of patient 8s medical record was completed on 8/9/23, and revealed the following: On 6/20/23, an initial comprehensive assessment was documented by the SW; 6 days after patient 8 was admitted. On 6/21/23, an initial comprehensive assessment was documented by the SC; 7 days after patient 8 was admitted. There was no documented evidence as to why the SW or SC did not complete their initial assessments of patient 8 within the required 5 days of admission. On 8/14/23 around 10:00 AM, the administrator was interviewed. She stated there were some big delays in care, everyone should be going out within 5 days. She further stated that was something she was going to have to get back on track.

Based on interview and record review, it was determined that the hospice governing body (GB) did not assume full legal authority and responsibility for the management of the hospice services and its fiscal operations. Specifically, the GB could not provide sufficient evidence they were involved in the ongoing operations of the hospice agency. --- 1. The hospice agency could not provide documented evidence of GB meeting minutes to show they were reviewing and addressing the functioning of specific hospice operations and services. 2. During entrance on 8/7/2023, the surveyors requested from the administrator the governing body meeting minutes. 3. In an interview on 8/7/2023 at 4:37 PM, the administrator stated that they did not have documentation of governing body meeting minutes. She further stated "people fly in once a month and that they get together and discuss the agency but that they do not have documentation of what was discussed or who was present."

Based on interview and record review, it was determined the hospice agency was unable to provide evidence that they had assessed the skills and competencies of all individuals furnishing care for 5 out of 7 employees and 1 of 1 volunteer. (Employee identifiers: 1, 2, 4, 5, 6, and 8). --- A review of personnel files was completed on 8/14/2023. There was no documented evidence that initial skills assessments or competency evaluations had been completed for 5 out of 7 employees (1, 2, 4, 5, and 6) and the volunteer (8). In an interview on 8/14/2023 at 10:00 am, with the administrator and the hospice intake coordinator. The administrator stated, ";I think the consensus is that we do not have them, we have been unable to locate them. We have looked in every place we thought they might be. They were done but where they have landed, we do not know. This is something we are going to need to improve on." The hospice intake coordinator stated ";I am positive that the director of nursing (DON) made sure that they were done. I actually saw them, but once they went to human resources (HR), I am not sure what happened to them."