Every finding on record at Compassionate Hospice of Las Vegas Inc

Upon patient record review, 2 of 14 (Patients #1,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients #1, #3: The record indicated this patient had oxygen order. Oxygen was not listed on the medication profile. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #2: The Volunteer was ordered for companionship per caregiver request. This frequency did not have a baseline frequency. Volunteer has not visited. This ordered cancelled during survey. Corrected on Site.

Upon patient record review, 3 of 14 (Patients #1,2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had a hospital bed, bedside table and wheel chair. These were not included on the Plan of Care. Corrected on Site. Patient #2: This patient had a wheel chair. This item was not included on the Plan of Care. Corrected on Site. Patient #3: This patient had a wheel chair. This item was not included on the Plan of Care. Corrected on Site.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: The Volunteer had visited this patient on 6/17, 7/8, 7/19 and 8/9/24. There was no frequency listed for volunteer services on POC.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #8: Did not have evidence that the tasks for shampoo-sink or tub-bath were observed during care or with a pseudo patient. These tasks indicated they were verbalized only during competency validation.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care (POC) Patient #1: The POC listed Aide visit frequency of, 5 X's per week. For 1st Benefit Week there were only 2 visits on 9/12/24 and 9/13/24 only.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3: The Hospice Election Statement indicated Start of Care date of 2/14/25. Hospice admitted patient on 2/15/25 (not 2/14/25).