Every finding on record at Valley Community Hospice, Inc.

Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. #3-Spiritual care assessment was completed on 06/05/24, greater than 5 days from the SOC dated 05/23/24.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. #4-Psychosocial assessment is blank with only date present, dated 06/11/24.

Upon patient record review, 1 of 14 (Patient #8) 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 #8-Oxygen is not listed on the medication profile, it is listed as a treatment on the plan of care.

Upon patient record review, 1 of 14 (Patient #4) 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. #4-Initial bereavement assessment was not completed.

Upon patient record review, 1 of 14 (Patient #4) 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. #4-Wound care order dated 07/25/24 for right knee is unclear. Order states to cleanse with wound cleanser, pat dry and apply bacitracin ointment every other day, cover with 4x4 bordered gauze dressing for 21 days, then reassess. The order does not state who will do the wound care on days when the nurse doesn't visit. Nursing frequency is for 2xwk.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. #5-CTI dated 6/25/24 does not contain the verbiage that the patient's life expectancy is 6 months or less.

Upon patient client record review, 2 of 14 (Patient #5,10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. #5-Wound care orders for 06/18/24 for left posterior ankle and left heel pressure ulcer to cleanse wound with Dakin's solution and pat dry with gauze. Apply Tetracyte and Mupirocin and medical grade honey to the wound bed, followed by Alginate AG. Cover with foam with silicone bordered dressing three times weekly. Documentation from nursing notes on 6/5,6/7,6/18,7/1,7/2,7/5 and 7/19/24 state "wound care done as ordered" - there is no details of what was performed. #10-Wound care orders dated 5/29/24 for sacrum and right buttock as follows: cleanse with wound cleanser and pat dry. Apply Tetracyte to wound bed, followed by Alginate AG, cover with foam with silicone bordered dressing 3Xwk and right heel wound cleanse with normal saline and pat dry, cover with 2X2 bordered dressing 2Xwk for 30 days. Nursing notes from 6/26,7/1,7/3,7/8,7/10,7/12, and 7/15 state "wound treatment done as ordered" - there is not detail of what was performed or to which site.