Every finding on record at Valley Regional Hospice Inc.

Observed in Record Review. In 2 of 10 active patient records reviewed, It was noted that the organization failed to ensure that both the patient and the primary caregiver received appropriate education and training from the hospice, in alignment with their responsibilities as outlined in the plan of care. For example, during home visit of RRHV#1, an interview with the patient’s family revealed that based on the son's understanding, he was irrigating the Foley catheter with 15 mL of acetic acid once daily, instead of the prescribed 30 mL twice daily. Additionally, upon review of record RRNHV#3, the patient was noted to be receiving oral morphine. However, there was no documented evidence of education provided regarding morphine as a high-risk medication during the initial assessment or in the first several visits, as required by agency policy. This finding was discussed with and confirmed by the DPCS Designee.

Observed in Record Review. In 3 of 10 active patient records reviewed, It was noted that the organization failed to ensure that the written hospice plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the treatment necessary to meet the patient's and family's needs. For example, in record RRHV#1, there was an order to irrigate the urinary catheter with 30 mL of acetic acid as needed; however, the order lacked specific indications and frequency for the irrigation. In record RRNHV#1, the order directed irrigation of a suprapubic catheter with 20 mL of acetic acid as needed did not have an indications or clinical justifications for the PRN instructions. In record RRNHV#2, the order included routine and PRN irrigation of a Foley catheter with 30 mL of acetic acid, yet did not specify the reasons for PRN use. These findings were discussed with and confirmed by the Director of Patient Care Services (DPCS) designee.

Observed in Record Review. In 4 of 10 active patient records reviewed, It was noted that the organization failed to ensure that care and services were delivered in accordance with the established hospice plan of care. For example, in review of record RRHV#1, the spiritual counseling was ordered to visit the patient once or twice per month; however, no visits were documented for the month of April 2025. Also noted, the medical social worker (MSW) was ordered to visit the patient twice per month for three months, yet only one visit was completed in both April and May. In record of RRNHV#1, five (5) PRN nursing visits were conducted, despite the plan of care indicating a maximum of three PRN visits. In record of RRNHV#4, the skilled nurse was ordered to visit the patient twice weekly, but only one visit was documented. In record of RRNHV#5, the skilled nurse was ordered to make three visits per week for two months; however, only two visits were completed during the week of the recertification period. These findings were discussed with and confirmed by the Director of Patient Care Services (DPCS) designee.

Observed in Record Review. In 1 of 10 active patient records reviewed, It was noted that the organization failed to ensure that written patient care instructions for the home health aide were prepared by the registered nurse assigned as the immediate nursing supervisor of the hospice aide. For example, during the record review of RRNHV No. 3, it was noted that the patient was taking Eliquis, an anticoagulant. However, the aide care plan did not include instructions to monitor for and report signs and symptoms of bleeding. This finding was discussed and validated by the DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1 it was noted lack of an update to the comprehensive assessment during IDG meetings the middle of August 2022 and the first IDG in September 2022 by the MSW and chaplain. During RR#2 it was noted lack of an update to the comprehensive assessment during IDG meetings in August 2022 by the MSW and chaplain. There was lack of documentation by the RN to update the comprehensive assessment during 1 IDG meeting in August 2022. During RR#3 it was noted lack of an update to the comprehensive assessment by the MSW and chaplain during 2 IDG meetings, one the end of August and the beginning of September 2022. This was discussed with the DPCS designee and the Clinical Manager.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1 it was noted the SN goals were not individualized. For example: Manage anxiety and restlessness to tolerate level during hospice stay. No signs of respiratory distress throughout hospice services. Provide education on each visit regarding oxygen safety to avoid any fatal incidents and Pain will be managed throughout hospice services. During RR#2 it was noted the SN goals were not individualized. For example: Pain will be managed throughout hospice services. Manage anxiety and restlessness to tolerate level during hospice stay. Assess and monitor for presence of edema and Provide education on each visit regarding oxygen safety to avoid any fatal incidents. During RR#3 it was noted the SN goals were not individualized. For example: Patient will remain free from injury related to agitation. Pain will be managed throughout hospice services. Resident will not harm himself or others. This was discussed with the DPCS designee and the Clinical Manager.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1 it was noted a frequency of visits established for the MSW and chaplain on the IDG/POC but lacked MSW and chaplain interventions based on the findings from their initial assessments. During RR#2 it was noted a frequency of visits established for the MSW and chaplain on the IDG/POC but lacked MSW and chaplain interventions based on the findings from their initial and updated assessments. During RR#3 it was noted a frequency of visits established for the MSW and chaplain on the IDG/POC but lacked MSW and chaplain interventions based on the findings from their initial and updated assessments. This was discussed with the DPCS designee and the Clinical Manager.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1-3 it was noted a frequency of visits established for the MSW and chaplain on the IDG/POCs but lacked goals based on the findings from their initial assessments. This was discussed with the DPCS designee and the Clinical Manager.

Observed in Record Review. In 8 of 16 patient records reviewed, the surveyor noted that the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example, record HV#1 the Chaplain had not completed an assessment within the five calendar days. HV#2 the MSW completed an assessment day 6. HV#3 the MSW and the Chaplain did not document completion of an initial assessment. RR#1, RR#4, RR#7, and RR#10 the Chaplain did not complete an assessment within 5 days. BR#1 the MSW completed the psychosocial and bereavement assessment day 7. RR#6 the MSW did not complete an assessment within 5 days. This was confirmed with the DPCS designee present.

Observed in Record Review. In 4 of 4 patient records reviewed, that included Bereavement services the surveyor noted that the organization had not specified the hospice care and services necessary to meet the family specific bereavement needs. For example, records BR#1, BR#2, BR#3 and RR#10DC were records of deceased patients and the records did not include a Bereavement POC. There was no documentation of a statement of the scope and frequency of the services necessary to meet the family’s needs and there was no documentation of measurable outcomes anticipated from implementing and coordinating a bereavement plan of care. The records did include documentation of mailings sent and phone calls made, but no POC. This was confirmed with the DPCS designee present.

Observed in Record Review. In 8 of 13 patient records reviewed, the surveyor noted that the written plan of care was not based on the patient’s goals and services required to meet those goals. For example, record HV#1 the POC goal indicated “wound care as ordered”. HV#2 the assessment included excoriated skin under the patient's breasts and a treatment medicated powder however the POC did not include any skin related goal. HV#3 the assessment indicated that the patient had an open decubitus ulcer on his buttock with treatment indicated however this was not included on the POC. RR#1 and RR#4 the assessment indicated that the patient had an open wound with treatment however this was not included on the POC. RR#3 the POC included goals for foley catheter care, Change urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered and Irrigate urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered with no individualized goal for the patient. RR#5 the POC included goals for impaired skin integrity, Provide/educate on wound care as ordered with no individualized goal for the patient. RR#6 the POC included goals for oxygen, Administer supplemental oxygen as ordered with no individualized goals for the patient. This was confirmed with the DPCS designee present.

Observed in Record Review. In 9 of 13 patient records reviewed, the surveyor noted that care and services were not provided in accordance with the plan of care. For example, record HV#1 the POC included 1 to 2 visits from the Chaplain each month, however there were no visits documented for 2 months. HV#2 the POC included 1 to 2 visits from the MSW each month, however there were no visits documented for 2 months. HV#3 the POC included 1 to 2 visits from the Chaplain each month, however there were no visits documented for 3 months. RR#1, RR#2, RR#3, RR#6, and RR#7 the POC included 1 to 2 visits from the Chaplain each month, however there were no visits documented for 1 month. RR#9 the POC included 1 to 2 visits from the MSW each month, however there were no visits documented for 2 months.This was confirmed with the DPCS present.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that staff failed to perform hand hygiene consistent with the organization's policy. For example, during visit HV#1 the RN failed to perform hand hygiene after removing gloves multiple times during the visit. HV#2 the HHA failed to perform hand hygiene after removing gloves multiple times during the visit. HV#3 the LVN failed to perform hand hygiene at multiple times after interacting with the environment and then returning to perform patient care. The organization's policy stated that hand hygiene is required after removing gloves and interacting/touching the patient's environment and intact skin. This was confirmed with the DPCS designee.

Observed in Record Review. In 2 of 9 patient records reviewed, that included hospice aide care the surveyor noted that the aide failed to provide care in accordance with the patient's POC. For example, RR#1 the hospice aide failed to provide a bed bath, pericare and oral hygiene as instructed in the POC on 8 visit dates. The documentation stated No. RR#7 the hospice aide failed to provide the partial bath, pericare, shampoo and back massage as instructed in the POC for every visit on multiple dates. The documentation stated either n/a or left blank. This was discussed with the DPCS designee.

Observed in Record Review. In 2 of 9 patient records reviewed, that included hospice aide care the surveyor noted that the aide was not supervised effectively. For example, in both RR#1 and RR#7 the frequency of supervisory visits met the standards, however the nurse did not identify that the aide was not following the Aide Care Plan instructions on the plan of care , such as performing a bed bath or shampoo at each visit. All areas of the Aide Supervisory Visit stated Excellent with no indication of missed care. As such this did not represent effective supervision as required by the standards. This was discussed with the DCPS present.

Observed in Tracer Activities. During review of the Volunteer program plan and discussion with leadership the surveyor noted that the organization did not have any active volunteers in the last year and had not documented efforts to recruit them. The Volunteer program plan did not include a documented recruitment or retention plan. This was confirmed with the Volunteer Coordinator and DPCS designee present.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor noted that the organization had failed to provide the patient a copy of the medication list. For example, HV#2 the home record did not include a medication list and the paid caregiver in the home stated that she gives the medications based on her knowledge as a med tech. HV#3 the LVN brought a medication list with him to leave in the home, there was no medication list prior to the visit. The patient had been admitted over 3 months prior. HV#1 the paid caregiver in the home could not locate the hospice admission packet and did not know if there was a medication list. This was discussed with the DPCS designee.

Observed in Record Review. In 2 of 2 discharged record reviews, the surveyor noted that the organization did not inform the physician of the availability of a discharge summary. For example, HV#9 the patient revoked care and the record did not contain any documentation that the physician had been informed of the availability of a discharge summary. This was confirmed with the DPCS designee present.