Every finding on record at Community Hospice of Northern Nevada, 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, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/01/2025 with a diagnosis of myelodysplastic syndrome. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 08/13/2025, the patient's hospice medication profile (printed on 08/12/2025) and SNF medication profile (printed on 08/13/2025) were compared. The following medications were documented on the hospice medication profile and not documented on the SNF medication profile: lovastatin 20 mg, take one (1) tablet every night (ordered 07/01/2025); hydrocortisone cream 1%, apply topically to rash 2x day for 7 days (ordered on 07/01/2025, was still showing active). Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/07/2025 with a diagnosis of Alzheimer's disease. The patient resided in an assisted living facility (ALF). During the home visit with the Spiritual Counselor [Personnel Record 6] on 08/13/2025, the patient's hospice medication profile (printed on 08/12/2025) and ALF medication profile (printed on 08/13/2025) were compared. The following medications were documented on the ALF medication profile and not documented on the hospice medication profile: nystatin cream, apply topically under left breast twice daily (ordered 12/11/2023); Chest congestion DM 10-100, take 10 ml every 4 hours as needed (ordered 06/10/2023); hyoscyamine 0.125 mg, every 6 hours as needed (ordered 05/17/2023); loperamide 2 mg, take two (2) capsules as needed (ordered 05/31/2023); ondansetron 8 mg, take every 8 hours as needed (ordered 07/06/2023). During the wrap-up call on 08/14/2025, the Administrator and Director of Compliance confirmed the findings, and the Director responded that medication reconciliations were "not optional. Should be completed with every comprehensive visit."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 07/01/2025 with a diagnosis of myelodysplastic syndrome. The patient resided in a skilled nursing facility. The plan of care ordered HA services twice weekly. The HA care plan dated 07/01/2025, and updated on 07/03/2025 and 08/06/2025, assigned the HA the relevant tasks: "Bathing-shower, transfer from bed/chair and chair to bed, routine catheter care, shaving, oral care." All tasks were to be completed on every visit until the 08/06/2025 revision, which changed shaving to weekly. The HA visit note dated 07/07/2025 documented, "Shower: No...Comments: bed bath; transfer from bed/chair and chair to bed, routine catheter care, shaving, oral care: caregiver completed prior to visit." The HA visit note dated 08/04/2025 documented, "Shower: No. Bed bath-Registered Nurse Case Manager (RNCM) notified. Transfer from bed/chair and chair to bed...not care planned for today... RNCM notified." The HA visit note dated 08/06/2025 documented, "Shower: No. Bed bath-RNCM notified. Transfer from bed/chair and chair to bed...not care planned for today...RNCM notified." CLINICAL RECORD 8: The patient elected hospice care on 06/13/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a group home. The plan of care ordered HA services twice weekly. The HA care plan dated 06/13/2025, assigned the HA the relevant tasks: "Bathing-bed bath, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, catheter care, shampoo, shaving, skin care, skin care-apply moisturizer, turn and position in bed, wash dishes, keep oxygen on while bathing, empty trash, provide companionship. All tasks were to be completed on every visit. The HA visit note dated 07/01/2025 documented: "bed bath, shaving, oral care, dressing, empty trash, wash dishes: No...Caregiver completed prior to visit. CLINICAL RECORD 14: The patient elected hospice care on 12/05/2024 with a diagnosis of malignant melanoma of the skin. The patient resided in an assisted living facility (ALF). The plan of care ordered HA services twice weekly. The HA care plan dated 12/05/2024 and updated on 08/06/2025, assigned the HA the relevant tasks: bathing-shower, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, shampoo, shaving, skin care, skin care-apply moisturizer, stand by assist with ambulation, change linens, empty trash, provide companionship. All tasks were to be completed every visit until the update; then, shaving and linens were changed to a weekly schedule. The HA visit note dated 05/01/2025 documented: "Change linens, empty trash-No. Caregiver completed prior to visit." The HA visit note dated 06/17/2025 documented, "oral care, change linens, empty trash-No. Caregiver completed prior to visit." The HA visit note dated 08/07/2025 documented, "Change linens, empty trash-No. Caregiver completed prior to visit. RN notified." CLINICAL RECORD 19: The patient elected hospice care on 07/02/2025 with a diagnosis of heart failure. The patient resided in a SNF. The plan of care ordered HA services twice weekly. The HA care plan dated 07/07/2025, assigned the HA the relevant tasks: "Bed bath, shampoo, hair care, skin care, turn and position in bed, perineal care, shaving, nail care, ear care, dressing, change linens, oral care." All tasks were to be completed on every visit. Aide frequency of twice weekly. The HA visit note dated 07/09/2025 documented: "Shaving, oral care, nail care: No, caregiver completed prior to visit." The HA visit note dated 07/14/2025 documented: "Shaving, oral care, nail care: No, caregiver completed prior to visit." The HA visit note dated 07/16/2025 documented: "Turn and position in bed, oral care, change linens: No, caregiver completed prior to visit." The HA visit note dated 07/21/2025 documented: "Turn and position in bed, shampoo, shaving: not care planned for today." During an interview and a joint clinical record review on 08/14/2025, the Administrator stated that "They had recognized issues with aide care plans and instituted a performance improvement plan to work on correcting these."

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure the Hospice Aide reported changes in the patient’s needs to the Registered Nurse. CLINICAL RECORD 8: The patient elected hospice care on 06/13/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a group home. The plan of care ordered HA services twice weekly. The HA care plan dated 06/13/2025, assigned the HA the relevant tasks: "Bathing-bed bath, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, catheter care, shampoo, shaving, skin care, skin care-apply moisturizer, turn and position in bed, wash dishes, keep oxygen on while bathing, empty trash, provide companionship. All tasks were to be completed on every visit. The HA visit note dated 07/01/2025 documented: "bed bath, shaving, oral care, dressing, empty trash, wash dishes: No...Caregiver completed prior to visit. There was no evidence that the Registered Nurse (RN) was notified of the change in the care plan and the patient's needs. CLINICAL RECORD 14: The patient elected hospice care on 12/05/2024 with a diagnosis of malignant melanoma of the skin. The patient resided in an assisted living facility (ALF). The plan of care ordered HA services twice weekly. The HA care plan dated 12/05/2024 and updated on 08/06/2025, assigned the HA the relevant tasks: bathing-shower, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, shampoo, shaving, skin care, skin care-apply moisturizer, stand by assist with ambulation, change linens, empty trash, provide companionship. All tasks were to be completed every visit until the update; then, shaving and linens were changed to a weekly schedule. The HA visit note dated 05/01/2025 documented: "Change linens, empty trash-No. Caregiver completed prior to visit." The HA visit note dated 06/17/2025 documented, "oral care, change linens, empty trash-No. Caregiver completed prior to visit." There was no evidence that the Registered Nurse (RN) was notified of the change in the care plan and the patient's needs. During an interview and a joint clinical record review on 08/14/2025, the Administrator stated that "They had recognized issues with aide care plans and instituted a performance improvement plan to work on correcting these."

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by personnel record review, document review, and interviews with the Administrator and Human Resources, which revealed that the agency failed to ensure the hospice professional met the personnel qualification requirements in the following areas: Failed to ensure the Social Worker who provided patient services directly was legally authorized and licensed in accordance with state law and regulation in 1 of 1 (100%) personnel records reviewed of a Social Worker. [HSRM.3.I/L784]. The effect of this deficient practice may pose a risk to patient safety and could result in the agency’s inability to meet the patient's needs for the condition of participation, CFR 418.114: Personnel Qualifications.

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel records reviewed of a Social Worker, the agency did not ensure that the Social Worker (SW) who provided patient services directly was legally authorized and licensed in accordance with state law and regulations. The Board of Social Work Examiners Statute: NRS 641B.500 "Representation as social worker without license. It is unlawful for any person to represent himself or herself as a social worker within the meaning of this chapter unless he or she is licensed pursuant to the provisions of this chapter. NRS 641B.505 Practice of social work without required license unlawful. 1. Except as otherwise provided in this chapter, it is unlawful for a person to engage in: (a) The independent practice of social work unless he or she: (1) Holds an active license as a clinical social worker or an independent social worker issued pursuant to this chapter; or (2) Holds an active license as a master social worker issued pursuant to this chapter and is engaging in the independent practice of social work under the conditions prescribed in NRS 641B.225. Agency policy #9-021.1 "Psychosocial Services-(state)" (dated 2003) (revised 10/2019 and 05/2020) stated in part, "The hospice will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and the interdisciplinary team and in accordance with the plan of care. Duties and responsibilities will be identified in appropriate job descriptions." Agency job description "Social Work" (dated 2003) (revised 12/2023) stated in part: "Position Qualifications. 6. Current licensure according to Medicare guidelines to practice in state of operations." Personnel Record 5: The SW (a MSW) was hired on 04/08/2024. The SW's "Initial Competency Skills Checklist-Social Worker" was signed as completed by a Master Social Worker (MSW) (who holds a state license) on 04/26/2024. During an interview and a joint personnel record review on 08/14/2025, the Administrator and the agency's human resources confirmed that there was no evidence of a current license for the SW, reporting that the SW did not have a license, as "it was not needed in this state." During an interview on 08/14/2025, the SW [Personnel Record 5] stated that "human resources and compliance advised her that a license was not needed in this state." A review of Personnel Record 5 (SW) hired on 04/08/2024 was conducted on 08/13/2025 with Human Resources and the Administrator. A copy of their current license was requested. It was reported the social worker did not have a license as "it was not needed in this state." An interview was conducted with Personnel Record 7 on 08/14/2025 during which time she advised upon hire "there was a lot of back and forth but human resources and compliance advised her a license was not needed in this state."

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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records. 2 of 13 (15%) records reviewed, the agency failed to ensure that the drug profile was updated at the time of each comprehensive assessment to reflect the most current prescription and OTC drugs being taken by or administered to the patient. Clinical Record 11: RN comprehensive recertification assessment dated 10/6/22 indicates the patient is oxygen dependent at 5 liters per minute. Oxygen is not included in the patient's current drug profile, physician orders, or patient's plan of care or updates. Clinical Record 8: Home Visit 1-Patient's daughter inquired of RN during home visit observation how to best administer Metamucil. RN offered suggestions as to how to dissolve in tea, Gatorade, or oatmeal. Metamucil is not listed on the patient's active medication list, physician orders, or patient's plan of care or updates.

It is required that performance improvement activities analyze the causes and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by a review of documents and interviews. During the review of the agency's QAPI (Quality Assurance Performance Improvement) documents and an interview with the agency DPCS (Director of Patient Care Services), it was revealed that there was no documented evidence of analysis of tracked data on adverse events. The organization had not documented the evaluation of the data, initiation of preventive strategies, or progress toward outcomes. The DPCS was able to articulate some activities that had been implemented with the intent to improve patient adverse events but none of these actions were documented. During the review of the agency's QAPI documents and an interview with the agency DPCS, it was revealed that there was no documented evidence that the agency's performance improvement activities included analyzing the causes and implementation of preventative actions related to processes of care, hospice services, operations, or adverse events. The organization has not documented the evaluation of progress toward outcomes nor was there documentation of new areas to improve or replicate as indicated by the results of data analysis. The DPCS was able to articulate some activities that had been implemented with the intent to improve processes of care, hospice services, operations, or adverse events but none of these actions were documented.

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. This standard was not met as evidenced by observations during home visits and a review of documents. The agency's policy titled Hand Hygiene states in part, "Hand decontamination using an alcohol-based hand rub should be performed before having direct contact with patient's...after contact with a patient's intact skin (when taking a pulse, blood pressure, or lifting a patient) …after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient… after removing gloves." 2 of 3 (67%) observations during home visits, the Registered Nurse failed to ensure that hand hygiene standard precautions and clean technique were followed as required by agency policy. Home Visit 1: Hand sanitizer used by the RN prior to donning gloves and preparing a clean area to place assessment tools. Hand sanitizer was not used by the RN while arranging physical assessment tools (i.e. blood pressure cuff, pulse ox, tympanic thermometer) on a clean area after obtaining them from a clear plastic zipped bag. The RN moved between touching the patient’s intact skin, and her computer and using each of the tools while assessing the patient without sanitizing in between each action. The RN did not sanitize her hands each time after removing gloves and prior to donning gloves again to perform another action. Home Visit 3: Hand sanitizer was used by the RN prior to preparing a clean area to place assessment tools and touching the patient with intact skin. Hand sanitizer was not used by the RN while moving physical assessment tools (i.e. blood pressure cuff, stethoscope, pulse ox, tympanic thermometer) from a clean area. The RN moved between touching the patient’s intact skin, and her computer and using each of the tools while assessing the patient without sanitizing in between each action. The agency's policy titled Hand Hygiene states in part, "...Hand decontamination using an alcohol-based hand rub should be performed before having direct contact with patient's...after contact with a patient's intact skin (when taking a pulse, blood pressure, or lifting a patient); ...after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ... after removing gloves."

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records. 1 of 12 (8%) applicable records in which aide services were to be provided, the agency failed to ensure that an aide plan of care was documented. Clinical Record 5: Physician Order written 4/19/22 to begin aide services 1W12 effective 4/24/22. There was no documented aide plan of care. There was no physician order to discontinue aide services and no documented evidence that aide services were declined by the patient.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records. 1 of 12 (8%)applicable records in which aide services were to be provided, the agency failed to ensure that an aide provided services as ordered in the plan of care. Clinical Record 5: Physician Order written 4/19/22 to begin aide services 1W12 effective 4/24/22. There were no documented aide visits performed. There was no physician order to discontinue aide services and no documented evidence that aide services were declined by the patient.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organizational procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties, the needs and concerns of patients and families coping with a terminal illness, and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 13 (8%) personnel records reviewed, the agency failed to ensure that each employee received an orientation addressing specific job duties and infection control. Staff 6: Hospice Medical Director-Date of Contract 6/1/2022-there was no documented evidence of an initial orientation addressing HMD specific job duties including infection control and organizational procedures and policies and procedures on advance directives. The Corporate HR Manager stated that the Hospice Medical Director had received no initial orientation. During the joint review of staff records, the Corporate HR Manager stated that in the future the corporate Hospice Medical Director would oversee an initial orientation for all agency medical directors that would include specific job duties, infection control, organizational procedures, hospice philosophy, and policies and procedures on advance directives to begin in 2023. During joint review of staff records, the Corporate HR Manager stated that the corporate Hospice Medical Director would oversee an initial orientation for all agency medical directors that would include specific job duties, infection control, organizational procedures, hospice philosophy, and policies and procedures on advance directives effective in 2023.