Every finding on record at Valley View Hospice, Inc.

Observed in Tracer Activities. The organization did not follow through with recommendations from previous surveys, as evidenced by the organization had not updated their ownership with the state of California and this ownership change happened in 2017.

Observed in Tracer Activities. On review of the organizations state of California license, the organization has a current license but the license does not have the correct owner and administrator listed and this changed in 2017. This was discussed with the owner and admin designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2 it was noted lack of nursing interventions and goals added to the POC for the multiple pressure ulcers identified during the initial RN assessment. This was discussed with leadership.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#4 it was noted lack of the number of PRN visits established on the POC the middle of January 2025.: BC: 1 - - Initial within 5 days from admission, and As needed for any bereavement needs, MSW: 1 - Initial assessment within 5 days from admission, With every re-certification, and as needed for any psych social needs, RN: 1 - Initial assessment, weekly, Every 14 days sup. Visit, with each recertification and as needed for any COC that require changes to POC, SC: 1 - Initial assessment within 5 days from admission ; With every re-certification and as needed for any spiritual needs. This was discussed with leadership.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that patient care services were not provided in accordance with the individualized plan of care. For example, a review of the medical record for RRNHV#1, revealed that the Registered Nurse (RN) visit frequency was ordered 1 visit every 2 weeks. There was no documented visit after week 1 of services. At the time of survey the patient was in week 5 of services. The Licensed Vocational Nurse (LVN) frequency was ordered 1 visit weekly. There was one LVN visit documented during week 3 of services. The Hospice Aide frequency was ordered 2 visits weekly. There was no documented evidence that a Hospice Aide visit was completed during the first benefit period. Example #2: A review of the medical records for RRNHV#2, and RRNHV#3, revealed that Hospice Aide frequency was ordered 2 visits weekly. There was no documented evidence that a Hospice Aide visit was completed during the first benefit period. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 3 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for RRNHV#1, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the first benefit period. The patient was on Hospice services for 5 weeks and there was no documented evidence that a Hospice Aide supervision visit was performed. This observation was reviewed with agency leadership.

Observed in Document Review. The organization is not licensed to provide the care, treatment, or services in California as required by law and regulation. For example, a review of the California Department of Public Health (CDPH) License for Hospice Services revealed that the License expired on 11/25/2024. The leadership team was not able to provide documented evidence that a renewed License for Hospice Services from CDPH was received. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to respect the patient's right to elect and revoke hospice. On review of RRDC#2 the documentation in the record noted the patient choose to come off of hospice due to a payor source change yet there was no completed revocation or transfer form noted in the record. This observation was reviewed with the Administrator and DON.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of RRHV#1 the admitting RN documented the patient with a stage 3 wound to the left buttocks however there was no documentation of an assessment of the wound to include all required elements such as size, color, drainage, or odor. In RRNHV#5 the patient was diabetic yet on the initial comprehensive assessment there was no documentation of an assessment of the endocrine system as the section on the visit note was left blank. These observations were reviewed with the Administrator.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care included goals that were individualized, specific, measurable, and time-bound. For example: through the records there was trend of goals not being specific, and measurable. In RRNHV#2 and example was Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level within next 2 weeks and will be reevaluated on the next IDG meeting. In RRNHV#4 the spiritual goals read like interventions such as Assess spiritual needs and preferences -Facilitate articulations of spiritual concerns -Provide non-judgmental listening -Assist in life review -Facilitate relaxation response -Spiritual and emotional needs to be addressed within 7 days -Re-evaluation at IDG meeting. In RRHV#3 an example was --Promote optimal rest status for Pt/Family/PCG within next 2 weeks and will be re-evaluated on the next IDG meeting. In RRNHV#7 there were interventions for nutrition yet no goal established. Similar examples of goals that were not specific, or measurable could be found in RRHV#1, RRNHV#5, RRNHV#6, and RRNHV#8. These observations were reviewed with the Administrator and DON.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#6 there was documentation of g-tube feedings and site care yet the issues were not reflected on the plan of care (POC). In RRNHV#7 there was mention of use of a purewick drain yet the device was not reflected in the POC. In RRNHV#8 the patient had an ileostomy but the device was not reflected in the care plans to guide its care. In RRHV#3, RRNHV#6, RRNHV#7, RRNHV#8 the MSW was seeing the patient yet there was no psychosocial care plan established. In RRNHV#6, RRNHV#7, RRNHV#8 the spiritual counselor was visiting the patient but no spiritual care plan to guide the care. These observations were reviewed with the Administrator, and DON.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 there was documentation of an oxygen concentrator in the home yet there were no physicians orders for the oxygen included on the plan of care. There was also documentation on the initial assessment that the patient had a stage 3 wound to the buttocks and wound care was done yet there were no treatment orders for wound care included on plan of care. In RRNHV#5 there was documentation of the patient with diabetes, and interventions on teaching the patient caregiver blood glucose monitoring, yet there were no physicians orders for the monitoring. In RRNHV#8 the patient had an ileostomy yet there were no specific physicians orders for ileostomy management. In RRNHV#9 there was an order on the medication profile for insulin 30 units subcutaneous daily every evening, yet the order did not specify what type of insulin was to be used. There were also no orders for blood glucose monitoring even though there was an intervention on teaching the importance of blood glucose monitoring. These observations were reviewed with the Administrator, Compliance Officer, and Office Manager.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the updated comprehensive assessment 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 IDG to IDG with no indication when or if goals had been achieved. This can be seen in RRHV#1, RRHV#2, RRHV#3, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10. These observations were reviewed with the DON, and Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, for active records, the organization failed to ensure the patient's care, treatment, and services were provided in accordance to the patient's individualized plan of care. For example: on review RRHV#2 the plan of care (POC) specified the RN visit every recert, yet the visits were documented weekly. In RRNHV#6 the RN was ordered a frequency of weekly yet the weeks 3 & 5 of October no RN visit was documented. In RRNHV#7 the RN per the plan of care was ordered weekly yet documented visits every other week. In RRNHV#9 the LVN was documenting weekly visit to the patient, yet there was no order LVN frequency per the POC. In RRNHV#10 the RN was ordered weekly yet documentation showed visits every other week. The MSW documented services were declined yet the POC noted social service visits every certification period. These observations were reviewed with the Administrator, DON, and Compliance Officer.

Observed in Data Session. on review of the QAPI program the surveyor noted the HCO did not have an effective, ongoing, organization wide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. The organization had a new electronic program for the program yet there was no documentation of meetings every 6 months as required by policy. There were annual reviews from January 2024, January 2022, and January 2021 but none from 2023.

Observed in Leadership Session. During the Data Management session the surveyor noted the HCO did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by there was no documentation of data analysis as the data collected stood alone and not compared over time for trends, patterns, and variations. In the annual review for 2024 example of documentation for analysis was vague for example for infection analysis it read the number of infection were relatively low to active census during the time. There were no trends noted. This observation was reviewed with the Administrator and Compliance Officer.

Observed in Record Review. In 2 of 10 patient records reviewed, for active records, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. For example: on review of RRNHV#6 the patient had a g-tube and was ordered a shower yet there were no specific instructions to instruct the aide on how to handle the g-tube while providing care. In RRNHV#7 the patient had an ileostomy, yet there were no instruction for the aide on how to handle the ostomy while bathing the patient. These observations were reviewed with the Administrator, and DON.

Observed in Tracer Activities. During the Volunteer program review the organization failed to document the cost savings achieved through the use of volunteers and the organization was unable to produce this documentation at survey. This observation was reviewed with the Compliance Officer.

Observed in Tracer Activities. During the volunteer program review it was noted the organization failed to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff as the documentation was unavailable at the time of survey. This observation was reviewed with the Compliance Officer.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.102, 418.58 and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 8 of 10 patient records reviewed, for active records, the organization failed to ensure the physician review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course. For example: on review of RRNHV#10 the physician utilized a template for the Certificate of Terminal Illness that read Per LCD guidelines, and supporting information from nursing assessment; Patient continues with slow steady declining and poor prognosis. With this, Patient currently meets the guidelines and criteria for Hospice care for Pt _2nd_certification period with Primary diagnosis of _Athscl heart disease of native coronary artery w/o ang pctrs (I25.10)_ for sign and symptoms management and comfort measures. I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient. The documentation lacked current subjective and objective findings. Additional examples could be found on RRHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, and RRNHV#9. These observations were reviewed with the Administrator, and Compliance Officer.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the patient record reflected the patient's care, treatment, and services. On review of RRBR#1 there was no documentation of the death visit. The RN interviewed stated she attended the patient death and produced a route sheet to verify yet there was no documentation of the visit made. In RRBR#2 there was also no documentation of a visit made at the time of the patient's death. These observations were reviewed with the Administrator and DON. Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the record contain information that reflect the patient's care, treatment and services. For example: on review of RRHV#1 there was documentation in the record that the patient had a wound to the left buttocks and wound care was done and taught to patient caregiver (PCG), yet there was no documentation of what type and steps taken for the wound care performed nor what was taught to the PCG. In RRHV#3 there was a primary terminal diagnosis changed from Alzheimer's on admission to Cardiac yet there was no documentation noted in the record of what prompted the change. These observations were reviewed with the Office Manager, and Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to ensure the discharge summary included all of the required elements. On review of RRDC#1 and RRDC#2 the discharge summary was a copy of an assessment yet did not include a summary of the patient's stay, current plan of care, or the latest physician orders. These observations were reviewed with the Administrator, and DON.

Observed in Competency Session. In 2 of 4 contracts reviewed, The organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice include all required elements. In review of the organization contract for therapy and DME there was no documentation that the contract contained 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 observation was reviewed with the Compliance Officer and the Administrator.

Observed in HR File Review. In 1 of 6 HR files reviewed, the hospice agency failed to document competency. In HR#4 for a chaplain who was also the bereavement coordinator, there was a competency documented for the bereavement coordinator role but the chaplain role did not have a documented competency evaluation. This was validated with the Director of Compliance.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 3's patient record review, it was noted the organization had not ensured the registered nurse updated the comprehensive assessment as frequently as the patient's condition required. For example: review of the patient's record revealed a comprehensive assessment with documentation RR# 3 was at high risk for skin break down and multiple interventions were put in place. Further review of the patient's record revealed a communication note with documentation that the assisted living staff had phoned the organization and informed the licensed vocational nurse that RR# 3 had a new pressure ulcer wound on the coccyx. Further review of the record revealed a registered nurse visit six days after the organization was informed of the new wound. This was reviewed and discussed with the Director of Nursing and the Quality Assurance Nurse and validated.

Observed in Record Review. In 11 of 11 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, and RR# 8's patient record review, it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of the patient records revealed an update to the plan of care (POC)/Interdisciplinary Group (IDG) dated one day prior to the surveyor review of the record with no documentation from the registered nurse or signatures from the IDG.

Observed in Data Session. During the Leadership and Data Management Session, it was noted the Leaders had not ensured the organization had an effective, ongoing, organization wide, data-driven quality assessment and performance improvement program. During the Leadership session, review of the QAPI documents revealed that the organization had only conducted one QAPI committee meeting in the last 37 months. In addition, review of the documents revealed there was no Performance Improvement Plan developed in the last 37 months. This was reviewed and discussed with Leadership and validated.

Observed in Data Session. During the Leadership and Data Management Session it was noted the organization had not analyzed data. For example: Review of the QAPI revealed while the organization collected data, there was no data analysis performed over the last 37 months since the last survey to determine treads in performance. This was discussed and reviewed with Leadership and validated. Observed in Data Tracer. During the Leadership and Data Management Session it was noted the organization had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was discussed and reviewed with Leadership and validated.

Observed in Record Review. In 2 of 7 patient records reviewed with Home Health Aide services, During HV# 1 and HV#'s patient records review, it was noted the registered nurse did not prepare specific written patient care instructions for the home health aide (HHA). For example: review of the patient record revealed HV# 1 had a stage 4 pressure ulcer to the coccyx and had experienced multiple pressure ulcers with wound care and wound dressings since the start of care approximately 21 months prior to the surveyor review of the patient record. Review of the HHA written instructions created at the start of care revealed no documentation regarding patient wounds or instructions on what to do if the dressing(s) came off during the bed bath. Further review of the HHA written instructions revealed the task of ROM [range of motion] Active-Passive every visit. Further review of the HHA written instructions revealed no documentation on if the ROM was to be active or passive, which joints, and what to do if the patient experienced pain. Review of HV# 3's HHA written instructions, dated at the start of care, approximately 18 months prior to this surveyor review of the patient record, revealed it was entered into the electronic medical record by a licensed vocational nurse and not signed by the RN. This was reviewed and discussed with the Director of Nursing and Quality Assurance Nurse and validated.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Condition of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and 418.58.

Observed in Competency Session. In 7 of 10 Personnel records reviewed, During HR# 1, HR# 2, HR# 4, HR# 5, HR# 6, HR# 8, and HR# 10's personnel record review, it was noted the organization had not ensured the skills and competence of the staff was assessed. For example: Review of the personnel records revealed no documentation staff competence was assessed as part of the orientation. This was discussed and reviewed with Leadership and validated.

Observed in Record Review. In 1 of 6 patient records reviewed with recertification, During HV# 1's patient record review, it was noted organization had not ensured Medical Director signed the certificate of terminal illness (CTI) prior to recertification. For example: review of HV# 1's patient record revealed documentation the current certification ended one day prior to this surveyor review of the patient record not signed and two additional recertification CTI's signed after the certification ended. This was reviewed and discussed with the Director of Nursing and Quality Assurance Nurse and validated.

Observed in Record Review. In 5 of 11 patient records reviewed, During HV# 1, RR# 1, RR# 3, RR# 4, and RR# 8's patient records review it was noted the organization had not ensured the patient record contained the registered nurse recertification comprehensive assessment and clinical notes per organizational policy. For example: review of HV# 1's record revealed a recertification dated the same day as this surveyor review of the patient record. Further review of the patient's record revealed no documentation of a RN recertification comprehensive assessment in the patient record. Review of RR# 1's patient record revealed a skilled nurse frequency of once a week. Review of the nursing visit notes revealed the last documented visit was dated approximately 15 days prior to this surveyor review of the record. Review of RR# 3's patient record revealed a skilled nurse frequency of once a week. Review of the nursing visit notes revealed the last documented visit was approximately 14 days prior to this surveyor review of the record. Review of RR# 4's patient record revealed a skilled nurse frequency of once a week. Review of the nursing visit notes revealed the last documented visit was approximately 15 days prior to this surveyor review of the record. Review of RR# 8's patient record revealed a skilled nurse frequency of once a week. Review of the nursing visit notes revealed the last documented visit was approximately 18 days prior to this surveyor review of the record. This was reviewed and discussed with the Quality Assurance Nurse and Compliance Director and validated.

Observed in Record Review. In 2 of 6 patient records reviewed with Recertification, During RR# 6 and RR# 7's patient records review, it was noted the organization had not ensured the plan of care was updated. For example: review of RR# 6's patient record revealed an update to the plan of care (POC)/Interdisciplinary Group (IDG) dated eight nine days after the certification with recertification discussion documentation. Review of RR# 7's patient record revealed three updates to the POC/IDG dated from 10 days after the certification with recertification discussion documentation. This was reviewed and discussed with the Director of Nursing and Quality Assurance Nurse and validated.

Observed in Record Review. In 11 of 11 patient records reviewed, During review of the patient records, it was noted that all patients' electronic medical records (EMR) documentation could be manipulated. For example: review of HV# 1's updates to the plan of care (POC)/Interdisciplinary Group (IDG) revealed the same frequencies for all disciplines since the start of care approximately 21 months prior to the surveyor review of the record. This was discussed and reviewed with the Quality Assurance Nurse. Review of the record later the same day revealed a change in the frequencies on past updates to the POC/IDG that had been signed by all the members of the IDG. This was reviewed and discussed with the Quality Assurance Nurse and Compliance Director and validated.