Every finding on record at Valley Oaks Hospice, Inc

Upon patient record review 2 of 14 (Patient #1,3) 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. Patient #1: The MSW initial psychosocial assessment was not completed until day 6. Patient #3: The MSW initial psychosocial assessment was not completed until day 6.

Upon patient record review 1 of 14 (Patients #6) 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. Patient #6: There is no evidence of an initial spiritual care assessment being completed by the SC or RN.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #2: The patient was admitted on 05/05/25. The RN revisited the patient on 05/07/25. Although there were LVN visits in between RN visits, the next documented RN visit was on 05/23/25, which is 16 days.

Upon patient record review, 4 of 14 (Patients #3, 4, 6, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: There is no evidence of interventions or goals for Ensure on the POC. There is no evidence of interventions or goals under cardiac for Pacemaker. Patient #4: The patient lives alone and has a neighbor that comes over twice daily. There is no family involved. There is no evidence of interventions or goals for a patient that lives alone. The patient is taking Methadone and Norco, however, there is no evidence of interventions or goals related to the use and education of narcotics for pain management. Patient #6: The patient is taking Trazadone for insomnia. There is no evidence of interventions or goals related to insomnia and use of Trazadone. Patient #9: The patient is prescribed daily Aspirin. There is no evidence of interventions or goals related to use of anticoagulants or bleeding on the POC.

Upon patient record review, 1 of 14 (Patient #9) 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. Patient #9: The patient developed a "Breast abscess" discovered on 05/26/25. There was no evidence of a wound order.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Patient #14: There was no evidence of a bereavement plan of care or bereavement letters in the record.

Upon patient record review, 4 of 14 (Patients #1, 5, 8, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The hospice aide assignment lists diet as tolerated. The patient diet is actually pureed with thin liquids. Patient #5: The hospice aide assignment states diet is as tolerated. The diet for this patient is mechanical soft. This patient has a supra pubic catheter. The aide assignment only lists for foley care. It does not specify that this is a suprapubic catheter. Patient #8: The hospice aide assignment states patient is on an as tolerated diet. The assignment calls for aide to encourage fluids. Although it does list that patient has aspiration precautions, the patient diet is actually mechanical soft with honey thickened liquids. Patient #9: The hospice aide assignment states that the patient is on an as tolerated diet. The patient is actually on a mechanical soft diet.

Upon patient record review, 3 of 14 (Patients #2, 7, 9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: The consents show that the patient requested a Hospice Election Addendum. There is no evidence in the record of this being provided to patient/family. Patient #7: The consents show that the patient requested a Hospice Election Addendum. There is no evidence in the record of this being provided to patient/family. Patient #9: The consents show that the patient requested a Hospice Election Addendum. There is no evidence in the record of this being provided to patient/family.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11: There is no evidence in the record that the discharge summary was sent to the patient's attending physician.

Upon patient record review, 6 of 11 (Patients #2, 3, 5, 6, 8, 9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #2, 3, 5, 6, 8, 9: Section of Consent/Election form to identify patient's choice of physician is left blank. The patient's right to choose physician is not clearly verified in records.

Upon patient record review 1 of 11 (Patient #2) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #2: The effective date of election is 3/22/22. The SOC/Initial Nursing Comprehensive Assessment was completed on 3/25/22.

Upon personnel record review, 1 of 1 applicable (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) (C) Shampoo, sink, tub, and bed Personnel #6: The form utilized by agency to document demonstrated competencies does not differentiate among different types of shampoo, but simply shampoo. Therefore, the standard is not met.

Upon patient record review 1 of 7 applicable (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: For visits 4/15/22 and 4/18/22, HA checked tasks as complete that were not part of RN assigned tasks: aspiration precautions, encourage fluids if not contraindicated, equipment used.

Upon patient record review, 1 of 11 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5: Patient was transferred in during the first benefit period. The CTI provided by the sending hospice and receiving does not include a narrative statement by the physician.

Upon patient client record review, 6 of 11 (Patients #2, 3, 5, 6, 8, 9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #2, 3, 5, 6, 8, 9: Section of Consent/Election form to identify patient's choice of physician is left blank. The patient's right to choose physician is not clearly verified in records.

Upon client record review, 1 of 11 (Patient #9) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.