Every finding on record at Valley Hospice, Inc.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, for community patients, it was revealed that the agency did not ensure that there was coordination of care to ensure the implementation of the interdisciplinary plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/22/2024 with a diagnosis of Malignant neoplasm of the Liver. During review of the updated plans of care, dated 11/26/2024 and 12/17/2024, there was a problem for “Blood Deficit due to coagulation deficit,” and the documented intervention stated, “Skilled Nurse, Social Worker/Counselor to monitor PT/PTT and or INR per physician order with frequency 1x/wk (one time per week)." The RN did not ensure that the appropriate coordination of care was documented on the plan of care to meet the patient's needs. During a joint review of the clinical record and interview with the Director of Clinical Services, on 01/07/2025, they stated that in a lot of their interventions they include all disciplines and acknowledged that this intervention was outside the social workers scope of practice,

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 19 (16%) clinical records reviewed, it was revealed that the agency did not ensure that the plan of care included planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 4/Home Visit 4: The patient elected the hospice benefit on 05/14/2024 with a diagnosis of acute on chronic respiratory failure. On a visit made by the RN (Registered Nurse) on 12/20/2024 the RN documented "visit made due to patient feeling nauseated and increased shortness of breath. Amoxicillin started for 7 days, and Haldol started for nausea. Patient reported pain 4/10 between shoulder blades." During the home visit with the RN (Personnel Record 7), on 01/08/2025, the surveyor observed the patient reporting pain off and on between the shoulder blades. During joint review of the clinical record and interview, on 01/08/2025 with the Director of Clinical Services, it was found that on the updated plan of care dated 12/31/2024 there was no documentation of planned interventions based on the identified problems of pain or nausea. CLINICAL RECORD 5: The patient elected the hospice benefit on 09/04/2024 with a diagnosis of malignant neoplasm of the colon. On the admission comprehensive assessment, dated 09/04/2024, the RN documented under the Neurological assessment, "dysphagia" and under the nutrition assessment "Dysphagia, loss of appetite, failure to thrive. Regular diet, swallowing assessment; aspiration precautions, dysphagia." On the initial plan of care, dated 09/04/2024, there was no documentation of planned interventions for the identified problem of dysphagia. In an interview with the Director of Clinical Services on 01/07/2025 she confirmed that the RN did not ensure that the dysphagia was included on the plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/06/2024 with a diagnosis of Cerebral Infarction. On the initial comprehensive assessment, dated 12/06/2024, it was documented that the family reports dysphasia. On a nursing visit made 12/12/2024 the RN documented "patient complains of trouble swallowing, food sitting in mouth when trying to be fed, only taking sips of water. Patient has experienced dysphasia in the past.” During joint review of the clinical record and interview with the Director of Clinical Services, on 01/08/2025, it was found that there were no planned interventions for the identified problem of dysphasia on the plan of care dated 12/17/2024.

. It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) bereavement clinical records reviewed revealed that the hospice did not ensure that there was documentation of bereavement services to families and other individuals following the death of the patient. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/21/2024 with a diagnosis of Alzheimer's disease. The date of death was 01/25/2024. During joint review of the clinical record with the Director of Clinical Services and the Chief Operating Officer it was revealed that there was no documentation that the hospice was following the plan of care created for the bereaved after the death of the patient. CLINICAL RECORD 18: The patient elected the hospice benefit on 01/03/2024 with a diagnosis of Multiple Myeloma. The date of death was 01/05/2024. During joint review of the clinical record with the Director of Clinical Services and the Chief Operating Officer it was revealed that there was no documentation that the hospice was following the plan of care created for the bereaved after the death of the patient. CLINICAL RECORD 19: The patient elected the hospice benefit on 09/16/2023 with a diagnosis of Sepsis. The date of death was 02/16/2024. During joint review of the clinical record with the Director of Clinical Services and the Chief Operating Officer it was revealed that there was no documentation that the hospice was following the plan of care created for the bereaved after the death of the patient. In an interview with these individuals, on 01/09/2025, they stated that they track the bereavement activity on a separate spreadsheet. Upon review of this spreadsheet revealed the names of patient/family that accepted bereavement, but it did not include documented evidence that the tasks on the bereavement plan of care had been performed.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that fire drills are held at least quarterly for each shift. Review of the fire drill logs on 01/08/2025, showed no written evidence of fire drills being conducted on the night shift of the inpatient unit between 11/22/2022 and 09/26/2023. The same review also showed no evidence of fire drills being conducted on the night shift since 05/07/2024. Therefore, first and second quarters for 2023, and the third and fourth quarters for 2024 did not have a fire drill documented on the night shift. On 01/08/2025, the Care Centers Manager (Personnel Record 6) reviewed the fire drill logs and confirmed that there was no documented evidence that fire drills for the night shift, for the dates in question, had occurred.

It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition. Per NPFA 101, 18.7.8, K-Tag 781 “Portable space heating devices shall be prohibited in all health care occupancies. Except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius)." This standard was not met as evidenced by interview and observation. The agency did not ensure that portable heaters were not used in patient rooms. During a tour of the inpatient unit (IPU) on 01/08/2025, a portable heater was observed to be in use in an occupied patient room. In an interview with the Care Centers Manager (Personnel Record 6) on 01/08/2025, she stated that portable heaters are allowed for use in patient rooms and are used periodically. She also stated that these heaters were reviewed and approved by the local fire marshal during their most recent inspection. She also stated that all portable heaters would be removed from patient rooms immediately.

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by interview and observation. The agency did not ensure that meals were served at the proper temperature. An observation tour of the kitchen at the inpatient unit (IPU) on 01/08/2025, revealed that was no documentation of the temperature checks of meals prior to serving. In an interview with the Chef for the agency's IPU on 01/08/2025, he stated that he, and the other food service staff, check the temperature of all meals prior to serving the meals to the patients but stated that they do not keep a record of these temperature checks. In an interview with the Chief Operating Officer, on 01/08/2025, she stated that she reconfirmed that documentation of temperature checks of food prior to serving are not maintained. The agency did not ensure that logs of the temperature checks of meals prior to serving were maintained.

Observed in Record Review. A review of 1 of 13 patient records revealed that the organization did not ensure the information it required to be gathered during patient assessments was completed. For example, a review of the medical record for RR#3 revealed that an initial bereavement risk assessment was not completed.

Observed in Record Review. In 5 of 13 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included specific assessed needs and outcome measures for specific care activities. For example, during a review of the medical record for RR#2, and RR#3, it was noted that the care plan included the following goal statement, “Patient’s pain goal is ______”. The goal statement did not include the specific patient pain goal and a method to measure the effectiveness of problem interventions. Example #2: A review of the medical record for RR#3, revealed that the patient’s primary diagnosis was Heart Failure, unspecified. The plan of care did not include a goal statement and patient care interventions related to the primary diagnosis of Heart Failure, unspecified. In addition, the plan of care included the following goal statement “Patient risk of injury is minimized”. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #3: During a review of the medical record for RR#5, the following goal statements were noted: “Patient will achieve optimal sleep/rest”; “Patient’s risk of injury is minimized”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. In addition, the plan of care goal did not demonstrate individualization for the goal statement: “Patient will implement interventions that decrease/control anxiety”. The patient was assessed with FAST scale score of 6a and the patient’s primary diagnosis was Alzheimer’s Dementia, unspecified. Example #4: During a review of the medical record for RR#6, the following goal statement was noted: “Patient’s risk of injury is minimized”. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #5: During a review of the medical record for RR#7, the following goal statement was noted: “Patient’s risk of injury is minimized”. The goal statement did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the VP of Quality Management.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RR#2, it was noted that at the time of the recertification assessment for the 5th benefit period, the clinician documented the presence of pain at the right shoulder and knees. The plan of care was not updated to include the patient’s specific pain goal and new interventions to address the patient’s increase in discomfort related to pain. Example #2: A review of the medical record for RR#3 revealed that at the time of the patient’s comprehensive recertification assessment the clinician documented: “At each visit he or his wife have reported one or more falls resulting from weakness and suspected syncope. His blood pressure continues with wide fluctuations while at rest ranging from 112 to 160. On [date omitted] he was started on a new medication by his cardiologist”. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. In addition, the plan of care was not updated with a goal statement and patient care interventions related to the primary diagnosis of Heart Failure, unspecified. This observation was reviewed with the VP of Quality Management.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure that its policy related to patient transfer to other service providers was implemented. For example, a review of the medical record for RR#9, revealed that during week seven of the first benefit period [for the present episode of care] the patient was transferred to a hospital. In addition, a review of the medical record for RR#13, revealed that during week seven of the 4th benefit period, the patient was transferred to a hospital. The hospice surveyor was not able to validate that the following requirements were completed: The receiving service provider was provided with a summary of care, treatment, or services the organization provided to the patient; and the patient's progress towards goals. This observation was reviewed with the VP of Quality Management.

Observed in Building Tour. The surveyor observed that the piping for approved automatic sprinkler systems was supporting other items. For example, the sprinkler pipe had blue cords, white cords and a coiled conduit resting on the sprinkler pipe. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.