Every finding on record at Canyon Idaho Home Care and Hospice, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. This standard was not met, as evidenced by clinical record review and interview. In 1 of 4 (25%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 4: The patient elected the hospice benefit on 11/24/2025 for a diagnosis of Parkinson's disease. The patient resided in an adult certified home (AH). During Home Visit 4 with Personnel Record 5 (Social Worker) on 02/18/2026, the hospice medication profile (printed on 02/17/2026) was compared to the AH medication profile. The following medications were listed on the hospice list and not on the AH list: "Bisacodyl 10 mg suppository. 1 daily as needed (ordered 11/24/2025); Fleet enema. 1 daily as needed, to be given after Bisacodyl (ordered 11/25/2025); Atropine 0.1 mg/ml. Every 8 hours as needed (ordered 12/05/2025); Haloperidol 2mg/ml. Every 6 hours as needed (ordered 12/05/2025)." The following discrepancy was noted: hospice had Senna S 50 mg/8.6 mg, take 1 tablet once daily (ordered 12/02/2025) vs AH had Senna S 50 mg/8.6 mg, take 1 tablet twice daily (ordered 02/12/2026). A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/20/2026. The Hospice Program Director "wanted to know how they were supposed to make sure facilities wrote all the medications in their lists if they faxed the orders over to them?" She said, " Sometimes it seems hard to get them to keep their lists updated."

It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment and per the plan of care. This standard was not met, as evidenced by clinical record review, and interview. In 5 of 19 (26%) clinical records reviewed revealed that social work services ordered on the Plan of Care (POC) did not follow the POC as ordered and based on the patient's or family's acceptance of these services. CLINICAL RECORD 4: The initial social work assessment dated 11/24/2025 and plan of care (POC) noted the following: "The family has not decided on a funeral home yet. The MSW (medical social worker) will follow up with the family about this. Recently moved from an ALF (assisted living facility) to a certified family home for a higher level of care. Frequency to be once monthly." A missed visit note dated 12/23/2025 documented "At this time, there are no known needs or concerns for this patient. MSW will continue to follow and intervene as needed." On 01/23/2026, the visit was marked as a missed visit without a note to document a reason. The interdisciplinary group notes/Plan of Care updates from the social worker reflected the same information as the initial assessment or missed visit notes. CLINICAL RECORD 8: The initial social work assessment dated 08/11/2025 and plan of care (POC) noted the following: "Assess bereavement needs of the caregiver, family, and other individuals that may impact their ability to cope with the patient's death. Frequency to be twice monthly visits." Visit was made on 08/20/2025. A note dated 08/29/2025 noted the following: "Patient had too many visits scheduled for the day. Will use PRN (as needed) next week if no visit plotted." There was not a follow up note or visit documented. A visit was documented on 09/17/2025. A note was documented for a missed visit on 09/30/2025 due to "scheduling conflict." A missed visit was documented for 10/16/2025 with a note that stated: "No known immediate needs or concerns at this time. MSW will continue contact with RNCM for any emergent needs." A visit was attempted on 10/30/2025 with a note: "Patient was napping, and MSW didn’t want to disturb her." A Plan of Care Order dated 11/12/2025 to 1/31/2026 changed the visit frequency to once monthly. A note for a missed social work visit on 11/30/2025 documented: "Patient has no known needs or concerns at this time. Visit will be missed due to holiday hours." A noted document on 12/30/2025 noted a social work missed visit "EOM/year. Unable to reschedule. Will utilize PRN visit if needed." There was no documented social work IDG note for the IDG dated 11/20/2025, although the social worker was present at IDG per the sign-in sheet. The social work interdisciplinary (IDG) note for 12/18/2025 documented: "No visit this IDT period." The IDG note on 12/31/2025 noted: "Patient has not been seen this IDT period." CLINICAL RECORD 10: The initial social work assessment dated 10/10/2025 and plan of care (POC) noted the following: "Frequency once a month in October, then twice a month for the rest of certification." A note for a missed visit dated 11/28/2025 stated: "Patient has no known needs or concerns at this time. Visit will be missed due to holiday hours and inability to move due to the end of the month." 12/17/2025, it was noted: "Phone call made." 12/30/2025, it was noted "Unable to reschedule visit due to EOM/end of year. PRN visit will be added if needed before the next scheduled visit." The interdisciplinary meeting notes and POC update dated 12/18/2025 noted: "Phone call with ***********. Discussed holiday and plans." The IDG note and POC update dated 12/30/2025 noted: "Patient has not been seen this IDT period." CLINICAL RECORD 14: The initial social work assessment dated 11/12/2025 and plan of care (POC) noted the following: "Visit frequency of once a month in November, then twice a month for the rest of the certification." The clinical record review revealed phone calls documented on 11/26/2025 and 12/17/2025. A missed visit was documented on 12/23/2025, which listed "No known needs or concerns for the patient at this time. MSW will continue to follow and intervene as needed." A missed visit was documented on 01/31/2026 with the reason listed as "Schedule conflicts." The IDG notes and POC updates listed "Patient not seen during cert period and no needs or concerns at this time." CLINICAL RECORD 19: The initial social work assessment dated 09/01/2025 and plan of care (POC) noted the following: "Social work visit frequency of once monthly for emotional support and assessment of needs." A missed visit note dated 09/30/2025 listed "scheduling conflicts" as the reason for the missed visit. A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/19/2025, during which time the social worker's missed visits were discussed and the lack of plan of care updates. It was discussed that missed visits "should only be at the patient or family/caregiver request, not scheduling conflict, holiday hours and that visits should not wait until the end of the month to be scheduled if the patient/family has accepted the social worker services." There should be plan of care updates for each IDT by every discipline that are relevant and "these cannot be accomplished with all visits being missed." A new social worker has been hired to help provide services as requested by patients/families.

It is required that written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met, as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 5: The hospice aide care plan dated 10/13/2025 thru 01/07/2026 included the following tasks: "Hygiene: Bath: bed; Bath: shower; Bath: shower chair; Nail care: may clean and/or file; Nail care; Companionship (added 10/28/2025); Skin care; Home management: clean bathroom after use; Hygiene: oral care; Hygiene: shampoo; Elimination: Report to RN if no BM (bowel movement in 3 days; Incontinent care." All tasks were to be completed every visit with an aide frequency of twice weekly. The aide care plan did not provide the aide(s) with specific instructions for which type of bath to provide for the patient during the visit(s). CLINICAL RECORD 17: The hospice aide care plan 09/06/2025 included the following tasks: "Assist to BSC (bedside commode)/toilet; assist with dressing; shampoo; perineal care; skin care; make patient bed; oxygen precautions; change adult diapers, bathing-bed bath; bathing-shower; assist with transfers; clean bathroom after care; change linen; incontinence care; oral care. All tasks were to be completed every visit with an aide frequency of twice weekly. The aide care plan did not provide the aide(s) with specific instructions for which type of bath to provide for the patient during the visit(s). A joint clinical record review and interview was conducted with the Hospice Program Director and the Clinical Managers on 02/19/2025, during which time it was agreed that the "nurses who entered the care plan should have only put one bath type with specific instructions for the aides."

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. A review of the volunteer program was conducted with the Hospice Program Manager, Administrator, and Clinical Managers on 02/19/2026, during which time the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged to 4.0%. The Volunteer Coordinator was off during the interview, and the information was provided by the Regional Volunteer Manager. The Volunteer Coordinator was given that role in October 2025 and, per the Hospice Program Manager, is "still being provided training for the role." During the interview, the Hospice Program Manager advised, "We are staffed well with volunteers; however still having difficulty getting patients/families to accept them into the homes and obtain the required hours. We will continue to increase our administrative hours in the meantime." A review of the volunteer program was conducted with the Hospice Program Manager, Administrator and Clinical Managers on 02/19/2026, during which time the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged to 4.0%. The Volunteer Coordinator was off during the interview and the information was provided by the Regional Volunteer Manager. The Volunteer Coordinator was given that role in October 2025 and and per the Hospice Program Manager is "still being provided training to the role." During the interview, the Hospice Program Manager advised "We are staffed well with volunteers however still having difficulty getting patients/families to accept them into the homes and obtain the required hours. We will continue to increase our administrative hours in the meantime."

It is required that the comprehensive assessment includes an initial bereavement 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. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included a completed initial bereavement assessment. Clinical Record 2: The patient elected the hospice benefit on 06/20/2024. The record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the comprehensive assessment included a completed initial bereavement assessment.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included goal(s) and intervention(s) based on problems identified in the initial comprehensive assessments. Clinical Record 1: The initial nursing assessment dated 09/13/2023 reported "Emotional Status: Patient agitated." The RN's narrative also stated, "She is agitated, very fidgety, not sitting still well." The POC dated 09/13/2023 lacked evidence of goal(s) and intervention(s) for agitation. The nursing assessment reported "Status: Genitourinary: Incontinent." The POC dated 09/13/2023, lacked evidence of goal(s) and intervention(s) for urinary incontinence. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the POC included goal(s) and intervention(s) based on problems identified in the initial comprehensive assessments.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the aide care plan. Clinical Record 3: The aide care plan dated 06/30/2024 ordered the tasks "Elimination: Incontinent Care", "Home Management: Change patient linen" and "Hygiene: Oral Care". The aide visit note dated 07/09/2024 reported "Patient refused" for the ordered tasks: "Elimination: Incontinent Care", "Home Management: Change patient linen" and "Hygiene: Oral Care". The record lacked evidence that the aide notified the RN of the changes in the patient's medical needs as related to the aide care plan. The Director of Clinical Services and the Alternate Director of Clinical Services stated in an interview on 08/20/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice emergency preparedness training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. 1 of 15 (7%) personnel records reviewed of staff that provide direct care, revealed there was no evidence of initial training in emergency preparedness policies and procedures consistent with their role. Personnel Record 1: The contract for the Medical Director was signed 11/14/2022. There was no documentation of any initial or ongoing emergency preparedness training since the contract was signed. During an interview on 3/29/2023, the Director of Nursing stated, "There was some confusion regarding the requirements for the Medical Director since he was a contract and not an employee," and confirmed there was no documentation of emergency preparedness training.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and observation. 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the patient's drug profile was updated to include a change in the patient's medication regimen. Clinical Record 7: The patient was admitted to Hospice on 2/10/2022 with a diagnosis of CVA. During discussion with the caregiver on the 2/28/2023 home visit observation, she reported the patient was no longer taking his blood pressure medication and stated, " He hasn't taken that for months because his blood pressure has been low." The drug profile for the benefit period dated 2/15/23-4/15/23 included documentation of Lisinopril for hypertension. During interviews with the directors of nursing for each site, they stated more education was needed on the medication review process.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. This standard was not met as evidenced by document review and interview. Review of the Governing Body Meeting minutes dated 3/4/2020, 3/16/2020, 5/11/2020, 1/15/2021, 4/14/2021, 1/22/2022, and 2/8/2023, revealed there was no documentation that the Administrator or the Alternate Administrator was appointed by the governing body and responsible for day-to-day operation of the hospice. Agency policy number A-05 titled, " Hospice Administrator" (reviewed 1/11/2023) stated in part under II: "The Hospice Administrator appointed by the Governing Body...." During an interview on 3/27/2023, the Administrator stated she was new and would be going to the corporate office for orientation soon. Review of the Governing Body meeting minutes dated 3/4/2020, 3/16/2020, 5/11/2020, 1/15/2021, 4/14/2021, 1/22/2022, and 2/8/2023, revealed there was no documentation that the administrator or the alternate administrator was appointed by the governing body and responsible for day-to-day hospice operations.

It is required that the hospice provides an initial orientation for each employee and contracted staff that addresses the employee's specific job duties. This standard was not met as evidenced by interview and personnel record review. 1 of 15 (7%) personnel records reviewed revealed no evidence of the completion of an initial hospice orientation. Personnel Record 1: The physician is a specialist in family practice. The personnel file contained a copy of the Medical Director Job description in addition to the signed contract dated 11/14/2022. There was no documented evidence in the personnel record that described the completion of an orientation to the hospice organization. During an interview with the Administrator and the Director of nursing it was confirmed that there was no evidence of an orientation for the Medical Director.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. 1 of 14 (7%) personnel records reviewed of staff that provide direct care, revealed there was no evidence of an assessment of the employee's skills and competency documented in the personnel record. Personnel Record 1: The contract physician's personnel record did not include documentation of a skills and competency assessment completed at hire. The contract was effective 11/4/2022. In an interview on 3/30/2023 with the Administrator and the Director of Nursing it was stated, "We didn't realize we needed to do that for the Medical Director."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that the record included correct clinical information including physician orders for all treatments and care that was provided. Clinical Record 2: On the Start of Care assessment dated 11/22/2022, the nurse documented that she inserted an indwelling catheter because the patient had self-catheterized for the prior 3 years but was now too weak to perform the task. There were no orders to insert an indwelling catheter during the admission, nor documentation of the size of catheter to be inserted and no orders for care of the catheter as needed (when to change or irrigate the catheter if needed). Additionally, orders for wound care included "Wound care as previously documented." There were no specific orders for wound care treatment and frequency documented on the Plan of Care (POC) or any other interim order documents. The SN visit frequency orders included orders for 10 as needed (PRN) visits, "To assess and evaluate for changes in condition, pain management, medication management, and/or in the event of a fall." The PRN orders did not include a PRN visit to address the wound or indwelling catheter. The SN visit dated 11/23/22 included documentation that wound care was provided as follows: Cleanse with wound cleaner, apply silver sulfadiazine and cover with non-adherent pad. Document 3: Agency policy number A-29 titled, Patient Records (reviewed 1/11/2023) stated in part under number 2, "Physician's orders shall be incorporated into the plan of care and renewed at least every 90 days." During an interview on 3/29/2023, the Director of Nursing confirmed that the clinical record was missing orders for the placement and care of the indwelling catheter and specific orders for the wound care.

It is required that information management policies and procedures (P&P) address how the hospice documents, collects, retrieves, protects, shares, and retains information in accordance with state and federal law and regulation. Patient clinical records are retained for six (6) years after the death or discharge of the patient unless state law stipulates a longer time period. This standard was not met as evidenced by document review and interview. 2 of 2 (100%) nursing facility contracts reviewed that were in place to provide routine, respite, and general inpatient care, revealed that the facilities were only required to retain clinical records for a period of 5 years rather than 6 years as required by regulation. Document 1: Review of the "Hospice and Nursing Facility" contract for hospice services including General Inpatient and Respite services dated February 8, 2023, revealed the contract stated under Section II, Records, Storage: Nursing Facility and Hospice shall each retain such records for five (5) years from the date of discharge." Document 2: Review of the "Hospice and Nursing Facility" contract for hospice services including General Inpatient and Respite services dated July 12, 2022, revealed the contract stated under Section II Records, Storage: Nursing Facility and Hospice shall each retain such records for five (5) years from the date of discharge." Agency policy number A-29 titled, "Patient Records " (Reviewed 1/11/2023), stated under number 7a: "Patient records shall be retained for at least ten years after the last day of patient care.' During an interview on 3/30/2023, the Administrator confirmed that record retention time frames stated in the contracts and in the policy were different from the requirement.