Every finding on record at Valir Hospice Care, LLC

Based on record review and interview, the hospice failed to ensure completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for three (Patients #4, 6 and 9) of 19 patients. --- Findings:Patient #4A review of the clinical record showed an election of the hospice benefit on 06/03/25 with no completion of the initial spiritual assessment from 06/03/25 to 06/18/25 (15 days after the election of the hospice benefit).  Documentation showed no patient or caregiver refusal of the initial spiritual assessment.Patient #6A review of the clinical record showed an election of the hospice benefit on 04/10/25 with no completion of the social worker assessment from 04/10/25 to 06/07/25 (58 days after the election of the hospice benefit), Documentation showed no patient or caregiver refusal of the initial spiritual assessment.Patient #9A review of the clinical record showed an election of the hospice benefit on 03/27/25 with no completion of the initial spiritual assessment from 03/27/25 to 04/23/25 (27 days after the election of the hospice benefit), Documentation showed no patient or caregiver refusal of the initial spiritual assessment.On 06/18/25 at 2:00 pm., Staff A stated the initial comprehensive assessment was to be completed within five days of the election of the hospice benefit and the initial spiritual assessment for Patients #4, 6 and 9 was not completed within the first five days of the election of the hospice benefit.

Based on record review and interview, the hospice failed to ensure hospice aide visits were provided in accordance with the plan of care for three (Patient #7, 8 and 14) of 19 patients. --- Findings:Patient #7A review of the plan of care dated 05/15/25 to 08/12/25 showed a hospice aide frequency of three visits per week.  A review of the clinical record showed the following:Hospice aide visits dated 05/20/25 and 05/22/25 for the week of 05/18/25 to 05/24/25 (two of three ordered visits completed). Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.A hospice aide visit dated 05/27/25 for the week of 05/25/25 to 05/31/25 (one of three ordered visits completed).  Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.A hospice aide visit dated 06/03/25 and a hospice aide missed visit dated 05/05/25 (due to the patient refused shower) for the week of 06/01/25 to 06/07/25 (one of three ordered visits completed).  Documentation showed no patient/caregiver refusal of other hospice aide services, no attempts to reschedule and no physician orders to change the ordered frequency.Hospice aide visits dated 06/10/25 and 06/12/25 for the week of 06/08/25 to 06/14/25 (two of three ordered visits completed).  Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.Patient #8A review of the plan of care dated 05/25/25 to 08/22/25 showed a hospice aide frequency of three visits per week.  A review of the clinical record showed the following:Hospice aide visits dated 06/03/25 and 06/05/25 for the week of 06/01/25 to 06/07/25 (two of three ordered visits completed).  Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.Hospice aide visits dated 06/11/25 and 06/13/25 for the week of 06/08/25 to 06/14/25 (two of three ordered visits completed).  Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.Patient #14A review of the plan of care dated 02/23/25 to 04/23/25 showed a hospice aide frequency of two visits per week.  A review of the clinical record showed the following:A hospice aide visit dated 03/13/25 for the week of 03/09/25 to 03/15/25 (one of two ordered visits completed).  Documentation showed no patient/caregiver refusal of visits and no physician orders to change the ordered frequency.A hospice aide visit dated 03/16/25 and a hospice aide missed visit (due to not wanting a shower) dated 03/20/25 for the week of 03/16/25 to 03/23/25 (one of two ordered visits completed).  Documentation showed no refusal of other hospice aide services, no attempts to reschedule the missed visit and no physician orders to change the ordered frequency.On 06/18/25 at 2:10 pm., Staff A stated the hospice aide frequency was not followed as ordered for Patients #7, 8 and 14.

Based on record review and interview, the hospice failed to ensure the hospice aide notified the supervising nurse of missed and incomplete visits for three (Patient #7, 8 and 14) of 19 patients. --- Findings:Patient #7A review of the plan of care dated 05/15/25 to 08/12/25 showed a hospice aide frequency of three visits per week.  A review of the clinical record showed the following:Hospice aide visits dated 05/20/25 and 05/22/25 for the week of 05/18/25 to 05/24/25 (two of three ordered visits completed). Documentation showed no notification to the supervising nurse of incomplete visits.A hospice aide visit dated 05/27/25 for the week of 05/25/25 to 05/31/25 (one of three ordered visits completed).  Documentation showed no notification to the supervising nurse of incomplete visits.A hospice aide visit dated 06/03/25 and a hospice aide missed visit dated 05/05/25 (due to the patient refused shower) for the week of 06/01/25 to 06/07/25 (one of three ordered visits completed).  Documentation showed no notification to the supervising nurse of the missed or incomplete visits.Hospice aide visits dated 06/10/25 and 06/12/25 for the week of 06/08/25 to 06/14/25 (two of three ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.Patient #8A review of the plan of care dated 05/25/25 to 08/22/25 showed a hospice aide frequency of three visits per week.  A review of the clinical record showed the following:Hospice aide visits dated 06/03/25 and 06/05/25 for the week of 06/01/25 to 06/07/25 (two of three ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.Hospice aide visits dated 06/11/25 and 06/13/25 for the week of 06/08/25 to 06/14/25 (two of three ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.Patient #14A review of the plan of care dated 02/23/25 to 04/23/25 showed a hospice aide frequency of two visits per week.  A review of the clinical record showed the following:A hospice aide visit dated 03/13/25 for the week of 03/09/25 to 03/15/25 (one of two ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.A hospice aide visit dated 03/16/25 and a hospice aide missed visit (due to not wanting a shower) dated 03/20/25 for the week of 03/16/25 to 03/23/25 (one of two ordered visits completed).  Documentation showed no notification to the supervising nurse of missed or incomplete visits.On 06/18/25 at 2:30 pm., Staff A stated the hospice aide failed to notify the supervising nurse of missed or incomplete visits for Patients #7, 8 and 14.

Based on observation, record review and interview, the hospice failed to ensure a branch location was accessible to the public during hours of operation possibly affecting all 211 current patients and all future potential patients. --- Findings:On 06/16/25 at 10:35 am., an observation was made at the branch location of the hospice lights being on.  The surveyor knocked on the door with no answer, hospice doors were locked, and no staff was observed to be present.  At 10:40 am., a knock on the door produced no answer.At 10:48 am., a call to the hospice was made, Staff A stated the nurses were out in the field and the hospice would send someone over as soon as possible.At 11:35 am., a knock on the door produced no answer.At 11:49 am., Staff A arrived at the hospice.At 11:52 am., Staff A stated the hospice staff were in and out of the branch location.

Based on record review and interview, the hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 130 patients and all employees. Findings: A review of administrative records showed no dated community-based risk assessment which addressed the agency and its patient population for the calendar years of 2020, 2021 and for January 01, 2022 to July 29, 2022. On 07/29/22 at 11:10 am, Staff C stated there was no documentation of when the all hazards risk assessment was completed for the calendar years of 2020, 2021 and for January 01, 2022 to July 29, 2022.

Based on record review and interview, the hospice failed to ensure a timely review of medications for two (Patients #4 and 7) of 13 patients. Findings: Patient #4 A review of clinical records showed a skilled nurse assessment dated 07/07/22 which documented the use of oxygen. Documentation showed no addition of oxygen to the medication profile. Patient #7 A review of clinical records showed a skilled nurse assessment dated 04/19/22 which documented the use of oxygen. Documentation showed no addition of oxygen to the medication profile. On 07/29/22 at 12:10 pm, Staff C stated oxygen was not added to the medication profile for Patients #4 and 7.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for twelve (Patients #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12 and 13) of 13 patients reviewed. Findings: Patient #1 A review of the plan of care dated 05/23/22 to 08/20/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 05/26/22 to 07/24/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 05/13/22 to 07/11/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 06/30/22 to09/27/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 04/26/22 to 07/24/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 04/17/22 to 06/15/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A review of the plan of care dated 05/13/22 to 07/11/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 04/08/22 to 07/06/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 07/08/22 to 10/05/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 03/31/22 to 06/28/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #12 A plan of care dated 03/18/22 to 06/15/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #13 A plan of care dated 03/20/22 to 06/17/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 07/29/22 at 11:50 am, Staff C stated the plans of care for Patients #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12 and 13 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure documentation of a QAPI Program was maintained for all 130 patients on service and all personnel employed by the hospice. Findings: A review of agency records showed no documentation of a QAPI Program for 2020, 2021 and for January 01, 2022 to July 29, 2022. On 07/29/22 at 12:15 pm, Staff C stated there was no documentation of the development of the QAPI Program for 2020, 2021 and for January 01, 2022 to July 29, 2022.

Based on record review and interview, the hospice failed to ensure evaluation and measurable progress of their PIP for 130 current patients and all employees. Findings: A review of QAPI records showed a PIP initiated in 2021. Documentation showed no measurable progress of the PIP in 2021 or 2022. On 07/29/22 at 12:15 pm, Staff C stated the PIP did not show measurable progress.

Based on record review and interview, the hospice failed to ensure wound measurements were coordinated with the long term care facility for one (Patient #4) of 13 patients reviewed. Findings: Patient #1 A plan of care dated 06/30/22 to 09/27/22 showed a skilled nurse frequency of one to two visits per week for fourteen weeks. A review of the electronic medical record showed the following: A skilled nurse visit dated 07/01/22 documented the presence of a pressure ulcer to the buttocks with no documented assessment of the pressure ulcer. Skilled nurse visit dated 07/07/22 for the week of 07/03/22 to 07/09/22 documented no wound measurements obtained by the hospice nurse or measurements obtained by the nursing home. Skilled nurse visits dated 07/10/22 and 07/11/22 for the week of 07/10/22 to 07/16/22 documented no wound measurements obtained by the hospice nurse or measurements obtained by the nursing home. Skilled nurse visits dated 07/17/22, 07/19/22 and 07/22/22 for the week of 07/17/22 to 07/23/22 documented no wound measurements obtained by the hospice nurse or measurements obtained by the nursing home. Skilled nurse visit dated 07/25/22 for the week of 07/24/22 to 07/30/22 documented no wound measurements obtained by the hospice nurse or measurements obtained by the nursing home. On 07/29/22 at 11:45 am, Staff C stated the hospice failed to show coordination with the nursing home regarding wound measurements.