Every finding on record at Desert Haven Hospice, LLC

Observed in Competency Session. On review of all HR records, there was no documentation to validate staff were provided emergency management training on hire. This was reviewed and validated in discussion hospice leadership.

Observed in Record Review. In 2 out of 2 bereaved patient records reviewed, the organization failed to complete a bereavement risk assessment after the death of the patient. Organization's Bereavement Policy states that the Bereavement Risk assessment is completed during first IDG after the patient's death. On RRBR #1 and RRBR #2, it was noted the organization did not complete a bereavement risk level for the patient after their death. This finding was discussed with Hospice leadership.

Observed in Record Review. On 1 of 2 live discharge records reviewed, the organization did not obtain orders for discharge from the Hospice. On RRDC #1, the patient was transferred to another hospice but there was no written physician order for that discharge from the agency. This finding was reviewed with Hospice leaders.

Observed in Record Review. In 2 of 4 active patient records reviewed, the organization did not include all services needed for the management of the patient on the plan of care. On RRHV #1, it was noted during the home visit that the patient had oxygen and she stated she was using it every night but there was no orders for the oxygen. In addition, it was noted that the patient had a wound that was being cared for by the nurses and there were no orders for the wound care. On RRHV #3, it was noted during the home visit that the patient had oxygen that she was using continuously but there was no order for the oxygen on the Plan of Care. This finding was reviewed with Hospice leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, nurse surveyor noted that the medical record did not contain medical equipment used by the patient in the home. During RRHV #1, it was noted on the plan of care that the patient had wheelchair, however it was observed in the home that patient had hospital bed, walker, oxygen concentrator, airflow mattress and shower bench that were not reflected on the plan of care. On RRHV #3, it was noted on the home visit that patient used a walker but the walker was not on the plan of care. This finding was reviewed with Hospice leadership.

Observed in Record Review. In 1 of 6 patient records reviewed, the Interdisciplinary team (IDG) did not review the plan of care at least every 15 days. On RRHV #1, the first IDG occurred 18 days after admission. This finding was reviewed with Hospice leadership.

Observed in Data Session. During QAPI session, it was noted the organization did not have documented hand hygiene goals for 2025 and subsequently, no data regarding improvements in hand hygiene compliance. This was reviewed with the administrator.

Observed in Record Review. In 2 of 2 bereavement records reviewed, it was noted that the organization had not ensured it developed a bereavement plan of care that specified the type of bereavement services to be offered. On review of RRBR #1 and RRBR #2, the post death bereavement plan of care was not developed. This finding was reviewed with Hospice leadership.

Observed in Record Review. On 2 of 4 active patient records reviewed, the organization did not completed a comprehensive spiritual assessment on admission. Agency policy states that on admission spiritual/cultural practices that include desired religious group, spiritual concerns or needs are addressed. On RRHV #2 and RRNHV #1, the nurse documented No to assessment of spiritual concerns and no chaplain was ordered. This finding was reviewed with Hospice leadership.

Observed in Record Review. In 1 out of 4 active patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During RRHV #1, the assigned tasks did not include specific instructions for care of the patient. For example, transfer from wheelchair to shower bench, instructions for showering using a shower bench, use of incontinence briefs, application of lotion, hair shampoo with specific ordered shampoo, instructions of oxygen that patient uses at night and PRN. This finding was reviewed and validated with the Hospice Leadership.

Observed in Record Review. In 3 of 3 active patient records reviewed with aide services, the nurse surveyor noted the organization had not supervised the hospice aide at least every 14 days. For example RRHV #1, the patient has been on service for over a month and there has not been a aide supervision completed. On RRHV #3, the patient has been on service for 2 months with aide services and no supervisory visit has been completed. On RRNHV #1, it was noted that the patient has been receiving aide services for 21 days and has not had a supervisory visit completed. This finding was reviewed with the Hospice Leadership.

Observed in Tracer Activities. On review of agency contracts, the organization did not have stipulations within the contract that included all required elements. On review of the pharmacy contract and therapy contract, the contract did not specify that services are provided only with authorization of hospice, serviced delivered in accordance with plan of care, and manner to coordinate with hospice. Agency was able update the therapy contract during the survey week. This finding was reviewed with Hospice leadership.

Observed in Competency Session. On review of all HR files, there was no documentation available to show that an orientation occurred. The organization has orientation binders with all the information of the orientation that they review but have not been documenting that the training occurred. This was reviewed and validated in discussion hospice leadership.

Observed in Tracer Activities. On review of agency contracts, the organization did not have stipulations within the contract that included all required elements. On review of the pharmacy contract and therapy contract, the contract did not specify the completion of background check for employees who provide direct patient care or have access to patient record. This finding was reviewed with Hospice leadership.