Every finding on record at Victory Hospice, Inc.

Based on record reviews and interviews, the Social Worker failed to complete a Bereavement Assessment (BA) of any grief/loss issues related to the patient's family as part of the initial comprehensive assessment for eight (#1, #2, #6 - #10 and #14) of fourteen (#1 -#14) records reviewed. --- Patient #1:Review of initial certification POC with a SOC date 08/04/25 showed a diagnosis of Malignant Neoplasm of the Pancreas. Documentation of the Initial Visit conducted by the Social Worker on 08/05/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment.  Patient #2:Review of initial certification POC with a SOC date 03/20/25 showed a diagnosis of Chronic Obstructive Pulmonary Disease. Documentation of the Initial Visit conducted by the Social Worker on 04/04/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment. Patient #6:Review of initial certification POC with a SOC date 08/30/25 showed a diagnosis of Heart Failure. Documentation of the Initial Visit conducted by the Social Worker on 09/03/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment.  Patient #7:Review of initial certification POC with a SOC date 06/12/25 showed a diagnosis of Alzheimer's Disease. Documentation of the Initial Visit conducted by the Social Worker on 07/24/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment.   Patient #8:Review of initial certification POC with a SOC date 08/28/25 showed a diagnosis of Malignant Neoplasm of the Pancreas. Documentation of the Initial Visit conducted by the Social Worker on 08/29/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment. Patient #9:Review of initial certification POC with a SOC date 09/10/25 showed a diagnosis of Hypertensive Heart Disease with Heart Failure.  Documentation of the Initial Visit conducted by the Social Worker on 09/12/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment. Patient #10:Review of initial certification POC with a SOC date 03/17/25 showed a diagnosis of Acute Myeloblastic Leukemia. Documentation of the Initial Visit conducted by the Social Worker on 03/21/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment.  Patient #14:Review of initial certification POC with a SOC date 01/20/25 showed a diagnosis of Intrahepatic Bile Duct Cancer. Documentation of the Initial Visit conducted by the Social Worker on 01/24/25 failed to provide evidence a BA was completed as part of the initial comprehensive assessment. During an interview on 09/23/25 at 1:30 PM, Admin1 stated the Bereavement Assessment is to be completed by the Social Worker.  During an interview on 09/25/25 at 8:50 AM, Admin1 stated the Bereavement Assessments were not completed by the Social Worker as required for Patients #1, #2, #6 - #10 and #14.

Based on record reviews and interviews, the SN staff failed to conduct a drug regimen review during the comprehensive assessment for two (#4 and #8) of fourteen (#1 -#14) records reviewed. --- Patient #4 A record review of Patient #4 for certification period 01/10/23 to 04/09/23 failed to provide evidence the SN Staff conducted a drug regimen review during the re-certification comprehensive assessment. Patient #8 A record review of Patient #8 for SOC certification period 02/22/23 to 05/22/23 failed to provide evidence the SN Staff conducted a drug regimen review during the initial comprehensive assessment. During an interview on 04/12/23 at 3:30 PM, RN1 stated no drug regimen review was conducted by the SN staff as part of the comprehensive assessments as required for Patient #4 and Patient #8.

Based on record reviews and interviews, the Agency staff failed to complete a bereavement risk assessment as part of the initial comprehensive assessment for eight (#1 - #6, #8 and #14) of fourteen (#1 -#14) records reviewed. --- Clinical record reviews failed to provide evidence the Social Worker completed a bereavement risk assessment as part of the initial comprehensive assessment for eight (#1 - #6, #8 and #14) of fourteen (#1 -#14) records reviewed. During an interview on 04/12/23 at 3:30 PM, RN1 stated the bereavement risk assessments were not completed as required for Patients #1 - #6, #8 and #14.

Based on record review and interviews the RN failed to conduct on site supervision of the Hospice Aide every 14 days as required for one (#7) of ten (#2, #3, #5 - #11 and #13) records reviewed with orders for Hospice Aide services. --- Patient #7 Review of clinical record #7 for re-certification period 02/06/23 - 04/06/23 revealed a primary diagnosis of Cerebrovascular Disease and orders for Hospice Aide services two times a week for six weeks. Review of documentation by the RN on Skilled Nurse Visit Notes for the weeks of 02/05/23 thru week 04/02/23 failed to provide evidence the RN conducted any supervisory visits of the Hospice Aide during this time period. During an interview on 04/12/23 at 3:30 PM, RN1 stated the RN failed to conduct supervisory hospice aide visits as required for Patient #7.