Every finding on record at Brighton Hospice Nevada, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected patient and family goals based on planned interventions and problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 10: The patient elected hospice care on 12/03/2025 with a diagnosis of non-rheumatic aortic stenosis. The initial nursing assessment on 12/03/2025 documented that the patient identified chronic pain, "Patient has chronic pain, especially in knees, due to arthritis. Patient takes Tylenol scheduled BID. Patient also suffers from headaches and pain in legs when touched." The hospice symptom follow-up visit on 12/26/2025 documented the patient's pain and edema in bilateral lower extremities (BLE): "Edema-trace BLE. Some pain verbalized when assessing edema." The plans of care effective 12/03/2025 through 03/02/2026 did not include documentation reflecting the patient's and family's goals, based on the documented planned interventions and problems identified in the initial and updated comprehensive assessments related to the patient's pain and edema. During a joint record review and an interview on 01/14/2026, the Senior Director of Clinical Quality confirmed that the individualized plan of care for clinical record 10 did not include patient and family goals based on identified planned interventions and problems related to pain and edema.

It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 4: The patient elected hospice care on 12/20/2025 with a diagnosis of chronic obstructive pulmonary disease. The initial comprehensive assessment dated 12/21/2025 identified wounds to the patient's right buttock, right leg, and right bilateral heels. The plans of care, effective 12/20/2025 through 03/19/2026, documented interventions for education and wound care: "Educate daughters and reinforce measures to maintain skin integrity...Clean with wound cleanser, pat dry, cover with dressing, wrap with rolled gauze, secure with tape." The plan of care documented the patient's goal: "Patient's wounds will not worsen and heal to maximum potential." The plan of care goal for the patient's wounds did not include a measurable outcome. "Worsen" and "heal" were not defined or measurable. CLINICAL RECORD 6: The patient elected hospice care on 01/02/2026 with a diagnosis of hypertensive heart disease. The initial comprehensive assessment, dated 01/02/2026, identified pain, energy limitations, and functional limitations as problems. The plans of care, effective 01/02/2026 through 04/01/2026, documented interventions for education and medications. The plan of care documented the patient's goals: "Patient recognizes energy limitations and understands/uses energy conservation techniques (hypertensive heart disease)...Patient will express satisfactory control of symptoms (Pain)...Patient will maintain optimum level of functioning appropriate for stage of disease process (Impaired physical mobility)." The plan of care goals did not include measurable outcomes. "Satisfactory control" and "optimum level" were not defined or measurable. CLINICAL RECORD 8: The patient elected hospice care on 01/06/2026 with a diagnosis of Parkinson's disease. The initial comprehensive assessment dated 01/06/2026 identified anxiety during dyspneic episodes as a problem. The plans of care, effective 01/06/2026 through 04/05/2026, documented interventions for education and medications. The plan of care documented the patient's goals: "Anxiety reduced and within manageable level during dyspneic episodes (Impaired Respiratory Status)." The plan of care goal did not include a measurable outcome. "Reduced and within a manageable level" were not defined or measurable. CLINICAL RECORD 14: The patient elected hospice care on 12/31/2025 with a diagnosis of Lung Cancer. The initial comprehensive assessment dated 12/31/2025 identified pain and dyspnea as problems. The plans of care, effective 12/31/2025 through 03/30/2026, documented interventions for education and medications. The plan of care documented the patient's goals: "Patient will report his breathing is being maintained at a comfortable/tolerable level (Impaired Respiratory Status)...Patient will be pain-free or verbalize an acceptable pain level with the current pain management regimen (Pain)." The plan of care goals did not include measurable outcomes. "Comfortable/tolerable level and pain-free or acceptable pain" were not defined or measurable. During a joint record review and an interview on 01/14/2026, the Senior Director of Clinical Quality confirmed that the individualized plans of care for clinical records 4, 6, 8, and 14 did not include measurable outcomes anticipated from implementing and coordinating the plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #7-009 (revision date 11/2024) stated in part, "Hand decontamination using an alcohol-based hand rub should be performed after removing gloves." In 1 of 4 (25%) home visits observed, the agency did not ensure hand hygiene was performed when indicated per the agency's policy. HOME VISIT 4/CLINICAL RECORD 4: The patient elected hospice care on 12/20/2025 with a diagnosis of chronic obstructive pulmonary disease. During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 4] on 01/14/2026, the LPN was observed performing wound care on the patient's left heel and coccyx. The LPN donned gloves, removed the soiled dressing, doffed the gloves, donned gloves, cleansed the left heel wound, applied a new dressing, doffed the gloves, and cleansed their hands. After removing the soiled dressing and doffing their gloves, the LPN did not decontaminate their hands. During an interview on 01/14/2026, the Senior Director of Clinical Quality confirmed the findings and the agency policy that hands should be cleansed after glove removal.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the "Volunteer Hours" report dated 01/01/2025 through 12/31/2025 with the Administrator and Volunteer Coordinator on 01/12/2026 revealed that volunteers provided 2.78% of day-to-day administrative and/or direct patient care services. The Volunteer Coordinator confirmed that volunteer utilization was below the required 5% for 01/01/2025 through 12/31/2025, stating, "The focus is recruitment. I have seventeen (17) volunteers, and we struggle a bit during the summer when the college students go home." During an interview on 01/12/2026, the Administrator confirmed that volunteer utilization was below 5% for 01/01/2025 through 12/31/2025, stating, "Our Volunteer Coordinator has been in her role less than a year and has been focusing on recruitment and retention. We have also increased our discipline frequencies for Hospice Aides and the psychosocial staff to meet the companionship needs of the patient when unable to match a volunteer." The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

Based on medical record review, interview, and policy review, the hospice agency failed to ensure the spiritual care assessment was completed within five days of the election of hospice care for three of 23 patients (Patient (P)5, P20, and P21). The failure of all members of the interdisciplinary group to complete the comprehensive assessment had the potential for the patient/family members spiritual and emotional needs to not be adequately addressed in a timely manner in the plan of care. Findings include: --- 1.Review of P5's "Hospice Nursing Initial Comprehensive Admission Assessment" revealed the date of the election of hospice care was 12/27/22. Review of a Care Coordination Note completed by the Spiritual Care Counselor (SCC)2 on 12/30/23 documented, due to the holiday, SCC will visit pt. [patient] Tuesday 1/3/22 [sic]. Review of the Spiritual Care Assessment and the Bereavement Risk Assessment revealed the visit was completed on 01/13/23 which is 17 days after the election of hospice care. 2.Review of P20's Hospice Nursing Initial Comprehensive Admission Assessment revealed the date of the election of hospice care was 02/02/23. Review of a Care Coordination Note completed by SCC3 on 02/08/23 documented, SCC[SCC3] was on military leave with the Army and was removed from all communication due to policy. No spiritual needs reported by RNCM. Review of the Spiritual Care Assessment and the Bereavement Risk Assessment revealed a visit was completed by SCC3 on 02/08/23, which is six days after the election of hospice care. 3.Review of P21's Hospice Nursing Initial Comprehensive Admission Assessment revealed the date of the election of hospice care was 09/24/22. Review of a Care Coordination Note completed by SCC2 dated 09/28/22 documented, Chaplain contacted spouse via phone and left detailed message. Initial assessment is due, however, chaplain missed visit. Chaplain scheduled to go along with RNCM or HHA next week. Review of the Spiritual Care Assessment and the Bereavement Risk Assessment revealed a visit was completed by SCC2 on 10/06/22, which is 12 days after the election of hospice care. During an interview on 02/15/23 at 2:45 PM, the Vice President (VP) of Regulatory Compliance stated that it was the hospice agencies expectation that the Spiritual Counselors complete the initial assessment within five days from the election of hospice services and that if a specific SCC was not available one of the other three spiritual counselors would be expected to complete the assessment. The VP of Regulatory Compliance also confirmed that the Spiritual Care Assessment for P5, P20, and P21 would be considered late and that only if a patient or a family member specifically requested that a visit occur after five days would it be considered acceptable. Review of the agency policy titled, "Initial/Reassessment," dated 10/26/16, revealed "The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit to identify patient/family/caregiver needs related to terminal illness ... The initial comprehensive assessment includes a psychosocial, environmental, economic, function, physical health, mental health, spiritual, spiritual, [sic] bereavement and pain assessment ... The bereavement component which includes: assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care."