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

Observed in Emergency Management Session. The disaster drills documented for 2024 and 2025 had the same after action critiques and recommendations to revise the emergency plan. There was lack of documentation that the recommendations resulted in updates for improvement in the emergency operation plan. This was discussed with the Administrator designee.

Observed in Record Review. In 9 of 10 patient records reviewed, The stated goals of records reviewed did not contain specific information that could be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. During RR#1 and RR#2 it was noted the goals lacked measurable outcome time frames, for example: RR#1; demonstrating safe use of bowel regimen, demonstrating proper feeding technique, modifying environment as recommended to enhance safety. In addition during review of the 8th benefit period it was noted lack of any documented goals on the POC for the 60 day certification. RR#2 lacked measurable outcome time frames, for example: verbalizing understanding of causative factors of dyspnea and appropriate interventions, participating in breathing treatment regimen, reporting pain is at or below acceptable level, following and administering pharmacological regimen safely and verbalizing understanding of non-pharmacological pain management techniques. RR#3 POC lacked measurable outcome time frames, for example: enumerating factors causing bladder disturbance, demonstrating the safe use of bladder regimen, discussing techniques on prevention of potential infections associated with bladder disturbance, displaying hemodynamic stability, e.g., blood pressure, cardiac output, peripheral pulse, renal perfusion. In addition it was noted during the RN assessment prior to the 10th benefit period the patient did not have swallowing difficulties, did not have a G-tube and was not a risk for aspiration the interventions however the POC contained the following goal related to the nutritional status: Demonstrating proper feeding techniques, observing aspiration precautions and performing NG/G tube care to prevent infection. During RR#4 it was noted a goal; performing NG/G tube care to prevent infection however the RN initial assessment did not indicate a G-Tube or naso-gastric tube. In addition, the eleven deficits identified in the POC lacked goals that had outcome time frames, for example: Identifying comfort measures and relaxation techniques to promote sleep. RR#5 goal related to nutrition documented as follows: demonstrating proper feeding techniques, and observing aspiration precautions however the RN assessment lacked documentation of swallowing deficits and need for proper feeding techniques. In addition the 13 deficits identified on the POC all lacked goals with outcome measure time frames. RR#6 POC goals lacked outcome measure time frames and had the same 13 deficits and goals documented for RR#5. During HV#1 and HV#3 record reviews it was noted lack of outcome time frames for all goals on the POC with 13 identified deficits which are the same as RR#5 and #6. HV#2 goals on the POC lacked measurable outcome time frames, for example: verbalizing understanding of causative factors of dyspnea and appropriate interventions, participating in breathing treatment regimen, reporting pain is at or below acceptable level. (Acceptable level 0-10 scale), following and administering pharmacological regimen safely, verbalizing understanding of non-pharmacological pain management techniques. This was discussed with the Organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted lack of any interventions on the POC during the 8th certification period of 60 days. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, There was lack of documentation during the every 14 day IDG meetings during the 8th certification period for RR#1 that the POC was reviewed or revised. The POC for 60 day certification was blank. This was discussed with the organization leadership.

Observed in Record Review. In 7 of 10 patient records reviewed, The organization failed to ensure the updated comprehensive assessments included information about the patient's progress toward goals and desired outcomes. Throughout the records reviewed there was a trend noted of a lack of documented progress toward goals and desired outcomes. The care plans remained the same from IDG to IDG and certification to subsequent certification periods with no indication when or if goals had been achieved. This can be seen in RR#1, RR#2, RR#3, RR#6, RR#7, HV#1 and HV#2 record review. These observations were reviewed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#1 record review it was noted the medication list in the patient home did not match the medication profile in the medical record. The patient's med list at home as verified by the daughter included Vitamin E 400 mg, Vitamin D3 2000 units, Fish oil 1000 mg, Vitamin C 1000 mg, none of which was on the medication profile. The daughter stated the patient no longer used Nitrostat that remained on the med profile in the medical record. This was discussed with the leadership team. Observed in Record Review. In 4 of 10 patient records reviewed, During RR#3, RR#2, RR#7 and HV#2 record review it was noted the initial bereavement assessment lacked the name of the person assessed as the bereaved, and the nature of the relationship with the patient. This was discussed with the organization leadership.

Observed in Document Review. In 1 of 4 contracts reviewed, The contract for therapy services lacked a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with leadership.

Observed in Record Review. In 1 of 11 patient records reviewed it was noted that the organization did not ensure that effective pain management was implemented. For example, during a review of the medical record for RR#5, the initial comprehensive assessment revealed that the pain assessment indicated the patient reported a pain level of 8 (severe) at the lower back area. The clinician instructed the patient to take Norco 5/325. This medication was ordered for moderate pain. This observation was reviewed with the QAPI and Disaster Planning Registered Nurse.