Every finding on record at Auburn Crest Hospice Treasure Valley, LLC

Observed in Record Review. In 1 of 16 patient records reviewed, the organization did not ensure that a comprehensive re-assessment was documented no less than every 15 days. In RRNHV#1 there was a span of 21 days between visits by a registered nurse. This RFI was reviewed with and validated by the Directors of Compliance, Nursing, and Social Services.

Observed in HR File Review. In 2 of 11 HR files reviewed, staff not provided emergency management training at least every 2 years. In HR#7 and HR#8, there was no documentation to show that staff were trained at least every 2 years on their emergency management responsibilities. This was confirmed by the Director of Nursing for Twin Falls and the Assistant Compliance Officer for the organization.

Observed in Record Review. In 1 of 15 patient records reviewed, anticipated discharge needs were not assessed. In RR#4, the surveyor noted that the initial bereavement assessment was not completed. This was confirmed by the Director of Nursing for Boise.

Observed in Record Review. In 4 of 15 patient records reviewed, interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. In HV#1, HV#2, RR#4, and RR#6, the surveyor noted a few IDG notes in May and June 2023 did not include documentation of progress toward goals. IDG notes missing the RN's prep notes. This was confirmed by the Director of Nursing for Boise.

Observed in Record Review. In 1 of 4 patient records reviewed on oxygen therapy, patient record was inaccurate or contained errors. For example, in RR#7, the surveyor noted that the patient had 2 oxygen orders: 1) Oxygen 2 lpm via nasal cannula continuous and 2) Oxygen 2 lpm via nasal cannula as needed for shortness of breath. In addition, the POC interventions indicated that patient was on Oxygen 1 lpm via NC continuous and Oxygen 2 lpm via NC for SOB. Upon review of the RN visit notes, the nurse documented that patient was on Oxygen 1 lpm inhaled via nasal cannula continuous. This was confirmed by the Director of Nursing for Boise. Observed in Record Review. In 1 of 15 patient records reviewed, the patient record was inaccurate or contained errors. In RR#12, the surveyor noted that aide services never began, but the aide care plan was not discontinued until 4 months later. Upon review of record, there was no documentation stating why aide services were no longer needed. This was confirmed by the Director of Nursing for Boise.

Observed in Record Review. In 2 of 15 patient records reviewed, the plan of care did not reflect the patient's current needs. In RR#12, the surveyor noted that aide services never began, but the aide care plan was not discontinued until 4 months later. This change was never communicated to the physician or IDG. In RR#13, the surveyor noted that aide services increased from 2 x week to daily; however, this change was never communicated to the physician or IDG. This was confirmed by the Director of Nursing in Boise.

Observed in Record Review. In 1 of 9 patient records reviewed receiving aide services, care was not provided according to hospice plan of care. In RR#11, the surveyor noted that the aide was completing tasks that were assigned for once a month on a weekly basis. For example, hospice aide will apply lotion to hands, forearms and legs once a month when CNA does nail care and once a month please soak hands/nails in warm soapy water to soften nails; however, aide was completing these tasks on a weekly basis. This was confirmed by the Director of Nursing for Twin Falls and the Assistant Compliance Officer for the organization. Observed in Record Review. In 1 of 9 patient records reviewed receiving aide services, care was not provided according to hospice plan of care. In RR#13, the visit frequency was 2 x week; however the aide was visiting daily. This was confirmed by the Director of Nursing for Boise.

Observed in Record Review. In 1 of 6 patient records reviewed receiving aide services, the registered nurse did not update written patient care instructions for the hospice aide. In RR#11, the surveyor noted that the aides visit frequency was changed from 1 x month to 1 x week, however, the registered nurse did not update the aide care plan to meet current needs. This was confirmed by the Director of Nursing for Twin Falls and the Assistant Compliance Officer for the organization. Observed in Patient Home. In 1 of 2 home visits conducted with patient's on oxygen therapy, the registered nurse did not prepare written patient instructions for the hospice aide. In HV#2 record review, the surveyor noted that the aide care plan did not provided instructions on whether or not the aide could remove the oxygen when bathing patient. This was confirmed by the Director of Nursing for Boise.

Observed in Patient Home. In 1 of 3 home visits conducted, patient record was inaccurate or contained errors. In HV#2, the surveyor noted some discrepancies between the facility and hospice medication lists. For example, the facility did not have Calmoseptine 0.44%-20.6% topical ointment and Potassium Chloride 20 mEq oral tabs listed even though they were prescribed in February and March respectively. In addition, patient was prescribed Metoprolol Succinate ER 50 mg oral tablet, and the facility had parameters listed, while the hospice medication list did not. This was confirmed by the Director of Nursing for Boise.

Observed in Record Review. In 2 of 11 HR files reviewed, criminal background check not conducted or documented as per law/reg. In HR#2, the surveyor noted that the background check for the Director of Nursing for Boise was not obtained within three months of hire. It was obtained seven months later. In HR#5, the surveyor noted that the background check for an LPN was obtained six months later. This was confirmed by the Administrator for Boise.