Every finding on record at Valley Star Hospice, Inc

Upon patient record review, 1 of 14 (Patient #1) 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 Patient 1: During home visit medication reconciliation, the patient stated that she takes Lasix 20mg 2 tabs daily and Flonase 2 sprays in each nostril once daily PRN for seasonal allergies. No evidence that the medication profile listed Lasix or Flonase as an active medication.

Upon patient record review, 1 of 14 (Patient #1) 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 1: During home visit medication reconciliation, the patient stated that she takes Lasix 20mg 2 tabs daily and Flonase 2 sprays in each nostril once daily PRN for seasonal allergies. No evidence that the current plan of care has orders for Lasix or Flonase.

Upon patient record review, 1 of 14 (Patient #3) 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 equipment and supply needs. Patient 3: RN documentation on 3/11/2026 indicated that the patient was dependent on a walker and cane. No evidence that a walker or a cane was added to the DME supply list at the time that the chart was surveyed.

Upon patient record review, 2 of 14 (Patient #3, 8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3: The current plan of care has a treatment order listing the patient as a DNR. The patient's signed advanced directive indicated that he is a full code. No evidence that the patient changed his status to a DNR. Patient 8: The Medical director documentation indicated that the patient was to be discharged due to extended prognosis. No evidence that the plan of care was updated to include discharge planning.

Upon patient record review, 1 of 5 (Patient #1) 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 Patient #1 medication profile includes "Diclofenac Sodium 1% Topical Gel, 2 grams topically four times daily" with no location identified.

Upon patient record review, 1 of 5 (Patient #1) 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 #1 plan of care includes "Diclofenac Sodium 1% Topical Gel, 2 grams topically four times daily" with no location identified.