Every finding on record at Desert View Group LLC

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 8, 10, 12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1, 2, 3, 8, 10, 12: Admission consent form that includes space for hospice benefit effective date, does not have space to identify patient's right to choose physician. There is no separate form to document chosen or refusal to choose, physician.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #4: Consents signed and effective date 1/21/24. RN initial assessment 1/28/24.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4: Patient consent forms signed 1/21/24 with hospice benefit effective date 01/21/24. Initial comprehensive assessment documented to have begun 01/28/24.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Patient #4: Patient consent forms signed 1/21/24 with hospice benefit effective date 01/21/24. Initial comprehensive assessment documented to have begun 01/28/24 with initial bereavement assessment 2/1/24.

Upon patient record review, 3 of 14 (Patient #9,10,13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #9: SOC 2/29/24. Patient complained of constipation 3/2/24. No update 3/13/24 IDG review. Problem of Gastro-Intestinal included for initial POC, but does not include goals and interventions and updates. Patient #10: SOC 3/16/24. Problem Altered Skin Integrity - right arm wound, but does not have any goals and interventions Patient #13: SOC 2/14/23. Problems included in initial POC, but no goals/interventions: Integumentary/skin altered skin integrity related to Braden score <14 and pressure ulcer stage 4. GI issue problem/needs Potential for altered bowel elimination related to constipation, GERD.

Upon client record review, 2 of 14 (Patient #3,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care Patient #3: Initial order for Volunteer 5x/week. No evidence of follow up assessment or care provided. Remains on IDG POC thru survey date. Interview with staff state this order was an error. In addition, foley catheter inserted 2/1/24 with order to Change every 30 days OR as needed for any signs of catheter encrustation, leaking, bleeding or catheter associated UTI. There is no documented evidence that catheter was changed. Catheter was changed 3/27/24. Patient #12: MSW frequency in orders and IDG POC throughout admission listed as 1 visit within 5 days. Patient was seen 1/19/23, 5/9, 6/14,7/25, 8/23/23, 9/29, 10/24, 11/16, 12/21/23.

Upon personnel record review, 1 of 14 (Personnel #8 ) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #8: Does not meet required qualifications of job description: "Bereavement Coordinator: Bachelor’s degree or equivalent theological degree from college or university. Experience with families/caregivers and patients through death/dying issues OR masters degree in social work with qualifications of experience clinical grief counseling." Personnel #8 is ordained and experienced minister in working with death and dying and has been employed with agency nearly 2 years.

Upon patient record review 3 of 14 (Patient #3, 6, 7) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: HA frequency is 1 per week - as needed. Visits provided 1/25, 2/14, 2/15, 2/16 only. Frequency remains in affect thru 3/13/24 IDG Patient #6: Initial IDG HA frequency of 2x/wk. Patient declined HA but POC and frequency orders not updated. Patient #7: HA visits 2/wk. Only visits provided were 2/26, 2/28 and 3/01. No updated orders related to stop. Also, IDG 3/13/24 identifies HHA frequency as 3x/week beginning 2/25/24. In fact the patient has not received any HA visits since 3/1/24 (no MD order). 2/23/24 order for 2xwk is only order.

Upon patient record review, 4 of 14 (Patient #1, 4, 5, 9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1: Patient consents signed 10/5/24 with hospice effective date blank and the CTI has benefit period of 10/4/23-01/01/24, beginning prior to effective and signature date. Patient #4: Patient consents signed 1/21/24 with hospice effective date of 1/21/24. There is no written CTI and no verbal certification within 48 hours. The CTI contains benefit period beginning 1/28/24. Patient #5: Patient consents signed 2/2/24 with hospice effective date of 2/2/24. The CTI included benefit period of 2/3/24-5/2/24. Patient #9: There is no documented narrative for initial CTI.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 8, 10)evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: Consents signed 10/5/23 with effective date of 10/5/23. Benefit periods identified as 01/02/24-03/31/24, when should have been 01/01/24-03/30/24. Patient #2: Admitted 01/10/24 in Benefit period #5. For Benefit Period #6, there is no verbal or written CTI within 48 hours and no physician documented narrative. Patient #3 Admitted 01/24/24 in Benefit Period #10. For Benefit Period #11, there is no verbal or written CTI within 48 hours and no physician documented narrative. Patient #8 SOC 2/29/24. Transfer in during benefit period #1. For Benefit Period #2, no verbal or written CTI within 48 hours. Patient #10: Admitted 3/16/24 in Benefit Period #2, there is no verbal or written CTI within 48 hours and no physician documented narrative.

Upon patient client record review, 7 of 14 (Patient #1, 2, 3, 8, 10, 12, 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 8, 10, 12: Admission consent form that includes space for hospice benefit effective date, does not have space to identify patient's right to choose physician. There is no separate form to document chosen or refusal to choose physician. Patient #2, 3,12,14: Admission consent form includes space to identify Hospice Benefit effective date. The space is blank.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: DNR Nevada POLST form dated 1/21/24 and signed by physician is incomplete. Side 1 Section A CPR: Both boxes are left blank. Attempt CPR or Allow Natural Death (Do not Attempt Resuscitation). Section B is marked as comfort measures only.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that an exercise was reviewed and updated. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documents provided to the Surveyor that the organization revised the HVA to address human caused hazards or hazardous materials emergencies in the documents provided. Explained this to the Office Manager and Care Coordinator who were the only staff onsite.

Observed in Tracer Activities. There was no evidence in the documents provided to the surveyor that the organization defined the patient population served and the extent that additional populations would receive care. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor to describe specific alternative means of communication or back up plan. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that described how the organization would communicate with authorities; did not contact EM response planners to determine role for their services. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that an emergency exercise was conducted. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. Record reviews were not done because neither the Administrator or DPCS were present while the Surveyor was onsite. Explained this to the Office Manager and Care Coordinator who were the only staff present. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the governing body ensured that QAPI included all services and demonstrated improvement in performance. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization demonstrated improvement in indicators related to palliative outcomes and services. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization analyzed data to identify areas for improvement. Explained this to the Office Manager and Care Coordinator who were the only staff present. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization collected data on performance, patterns, trends, and variations. Explained this to the Office Manager and Care Coordinator who were the only staff present. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization collected data on performance, patterns, trends, and variations. This was reviewed with the owner.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization identified the frequency of data collection. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization selected performance improvement activities that affect palliative outcomes, patient safety, and quality of care. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that the organization had an effective performance improvement program. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that performance improvement was organization wide. Explained this to the Office Manager and Care Coordinator who were the only staff present. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that leaders set priorities for data collection, performance improvement activities, and patient health outcomes. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. The Surveyor did not observe infection control practices during a home visit. Neither the Administrator were DPCS were present while the surveyor was onsite. Reviewed Infection Control and QAPI binders but did not find any indication or documentation that the RFIs previously scored were corrected. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that infection control goals included improving compliance with hand hygiene. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that infection control goals to limit unprotected exposure to pathogens from equipment, devices and supplies was addressed. Explained this to the Office Manager and Care Coordinator who were the only staff present. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that infection control goals to limit exposure to pathogens during procedures was addressed. Explained this to the Office Manager and Care Coordinator who were the only staff present. Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that infection control goals to limit unprotected exposure to pathogens were addressed. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. There was no evidence in the documentation provided to the surveyor that staff were educated on vaccine, non-vaccine control measures, and diagnosis, transmission and impact of influenza. Explained this to the Office Manager and Care Coordinator who were the only staff present.

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.56, §418.58, and §418.60.

Observed in Emergency Management Session. There was no evidence in the documentation provided to the surveyor that an exercise was reviewed and updated. This was reviewed with the owner.

Observed in Emergency Management Session. there was no evidence in the documents provided to the surveyor that the organization revised the HVA to address human caused hazards or hazardous materials emergencies in the documents provided. This was reviewed with the owner.

Observed in Emergency Management Session. There was no evidence in the documents provided to the surveyor that the organization defined the patient population served and the extent that additional populations would receive care. This was reviewed with the owner.

Observed in Emergency Management Session. There was no evidence in the documentation provided to the surveyor to describe alternative means of communication or back up plan. This was reviewed with the owner.

Observed in Emergency Management Session. There was no evidence in the documentation provided to the surveyor that described how the organization would communicate with authorities; did not contact EM response planners to determine role for their services. This was reviewed with the owner.

Observed in Emergency Management Session. There was no evidence in the documentation provided to the surveyor that an emergency exercise was conducted. This was reviewed with the owner.

Observed in Record Review. In 3 of 3 patient records reviewed, there was no evidence in the documentation provided to the surveyor that goals were specific. For example: Bereaved will have knowledge of how to utilize bereavement services; family will cope and accept death; patient will control his blood sugar with current medication and diet; patient will be comfortable and will; patient will not develop complications relative to impaired mobility; patient will keep hydrated daily. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the governing body ensured that QAPI included all services and demonstrated improvement in performance. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization demonstrated improvement in indicators related to palliative outcomes and services. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization analyzed data to identify areas for improvement. This was reviewed with the owner. Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization collected data on performance, patterns, trends, and variations. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization identified the frequency of data collection. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization selected performance improvement activities that affect palliative outcomes, patient safety, and quality of care. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that the organization had an effective performance improvement program. This was reviewed with the owner.

Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that leaders set priorities for data collection, performance improvement activities, and patient health outcomes. This was reviewed with the owner. Observed in Leadership Session. There was no evidence in the documentation provided to the surveyor that performance improvement was organization wide. This was reviewed with the owner.

Observed in Patient Home. In 1 of 1 home visits conducted, an LPN did not perform hand hygiene before entering his visit bag twice. This was reviewed with the owner.

Observed in Infection Control Tracer. There was no evidence in the documentation provided to the surveyor that infection control goals included improving compliance with hand hygiene. This was reviewed with the owner. Observed in Infection Control Tracer. There was no evidence in the documentation provided to the surveyor that infection control goals to limit exposure to pathogens during procedures was addressed. This was reviewed with the owner. Observed in Infection Control Tracer. There was no evidence in the documentation provided to the surveyor that infection control goals to limit unprotected exposure to pathogens from equipment, devices and supplies was addressed. This was reviewed with the owner. Observed in Infection Control Tracer. There was no evidence in the documentation provided to the surveyor that infection control goals to limit unprotected exposure to pathogens were addressed. This was reviewed with the owner.

Observed in Infection Control Tracer. There was no evidence in the documentation provided to the surveyor that staff were educated on vaccine, non-vaccine control measures, and diagnosis, transmission and impact of influenza. This was reviewed with the owner.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion during the EM session it was noted that the organization had not evaluated its emergency management program and operations plan every two years or more frequently. For example, the Hazardous Vulnerability Analysis was dated 2020 and the plan included a document of evaluation of the plan dated 12/16/2020. This was confirmed with the owner present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization had not utilized an all hazards approach when conducting the hazard vulnerability analysis. For example, the organization's hazard vulnerability analysis did not include Human caused hazards or Hazardous materials. This was confirmed with the owner present.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion in the EM session it was noted that the emergency plan did not define the patient population and did not address the extent to which additional populations may be cared for during an emergency. This was confirmed with the owner present.

Observed in Emergency Management Session. During review of the Emergency Management plan and discuss during the EM session it was noted that the plan did not describe alternative means of communication or back up communication methods. This was confirmed with the owner present.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion in the EM session it was noted that the organization’s communication plan did not describe how it would communicate about its needs to authorities and the organization had not contacted emergency response planners in their region to determine if there was a role for their services. This was confirmed with the owner and administrator present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization had not conducted exercises to test its emergency operations plan. For example, during review of the emergency management plan it stated that the exercises were to be completed, however there was no documentation of any exercises or actual events. This was confirmed with the owner who was present.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that prior to care the organization failed to inform in writing of the treatment and services. During RRHV#1 and #3 this was confirmed with the owner present, she stated that she had been aware that the documentation was not in the homes and the staff had been asked to bring it out however it was not available in the patient home on visit.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services it was noted that the bereavement assessment was not completed by the social worker, as required by the organization's policy. For example, in record RRBR#1 the initial bereavement assessment and the bereavement assessment after the patient's death were both documented by the spiritual counselor. RRHV#1 and RRBR#2 the initial bereavement assessment was documented by the spiritual counselor. The organization's policy stated that the bereavement assessments were to be completed by the medical social worker. This was confirmed with the owner and administrator present.

Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that the patient record was inaccurate. For example, in RRNHV#1,RRNHV#6 and RRHV#3 the initial bereavement assessment narrative stated the plan for a post death plan of care including interventions of beginning 1 month, 3 month 6 month 9month and 12 month mailings post death mailings. The patient's had not died. This was confirmed with the nurse present.

Observed in Record Review. In 12 of 12 patient records reviewed, it was noted that the written plan of care was not based on the patient's goals and the time frames, settings, and services required to meet the goals. For example in records RRHV#1-3, RRNHV#1-7 and RRBR#1-2 the POC goals did not have time frames for achieving goals. For example, in 12 records the goals were general and not based on identified problems, such as Healing road to peace and Blood sugar management for pt. comfort.. This was discussed and confirmed with the owner, administrator, DCPS and nurse present.

Observed in Record Review. In 2 of 3 patient records reviewed, that included aide services it was noted that care was not provided according to hospice plan of care. For example, record RRHV#3 the plan of care stated that the aide was to assist the patient's 3 times a week and during one week the aide documented 4 visits. There was no change to the POC and no supplemental order. In record RRHV#2 the first POC/IDG stated aide frequency of 7 days a week and the second POC/IDG stated aide frequency of 3 times a week. The aide had been seeing the patient 14 times a week; 2 two hour visits a day. This was confirmed with the administrator and nurse present.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the organization's governing body did not ensure the quality assessment and performance improvement program met, involvement of al services provided by the organization and did not take action to demonstrate improvement in the organization's performance. This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the quality assessment and performance improvement program did not demonstrate improvement in indicators related to palliative outcomes and hospice services. This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the agency had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was confirmed with the owner present. Observed in Data Session. During discussion in the Data session and review of the data plan and data collected it was noted that the organization had not analyzed and compared internal data over time to identify levels of performance, patterns, trends and variations. For example, the HCO did not collect patient satisfaction data. QAPI data was collected, but not compiled in a manner it could be analyzed or used to identify performance trends or variances and the organization did no longitudinal analysis of data.  This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the plan it was noted that the organization did not identify the frequency of patient satisfaction data collection.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the organization did not select performance improvement activities that affect palliative outcomes, patient safety and quality of care. This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the organization did not have an effective ongoing organizationwide data driven quality assessment and performance improvement program. This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that as part of performance improvement leaders did not set priorities for data collection, performance improvement activities and patient health outcomes. This was confirmed with the owner present. Observed in Data Session. During the Data session discussion and review of the data plan and data it was noted that the organization's performance improvement did not occur organizationwide. This was confirmed with the owner present.

Observed in Patient Home. In 2 of 2 home visits conducted, when the staff brought equipment/bag into the home it was noted that the organization had not implemented infection prevention and control activities. For example, during RRHV#1 the LPN did not clean any of the equipment prior to returning the items, such as stethoscope, pulse ox, B/P cuff, to the clinical bag per agency policy. During RRHV#3 the RN did not clean the stethoscope prior to returning it to the clinical bag and she used a retractable tape measure and allowed it to retract after use, pulled it out and wiped it with alcohol wipe and immediately retracted not allowing dry time. This was discussed with the owner present and the staff. Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that the staff failed to perform hand hygiene consistent with policy.  For example, during RRHV#1 and #3 the staff failed to follow the Bag Technique policy that required hand hygiene before entering the clinical bag. This was discussed with the staff and owner present.

Observed in Data Session. During the Data session discussion and review of the Infection Control plan it was noted that the organization's written goals did not include improving compliance with hand hygiene guidelines. This was confirmed with the owner present. Observed in Data Session. During the Data session discussion and review of the Infection Control plan and data it was noted that the organization did not comply with hand hygiene guidelines. For example, the organization had not collected and used data obtained from supervised home visits while staff was providing direct patient care. The organization had collected raw data sheets from observing staff wash hands in the offices bathroom sink in 2023 and had not collected data the previous 2 years. This was confirmed with the owner, administrator and office manager present. Observed in Data Session. During the Data session discussion and review of the Infection Control plan it was noted that the organization did not have infection control goals so did not include Limiting the spread of infections associated with procedures. This was confirmed with the owner present. Observed in Data Session. During the Data session discussion and review of the Infection Control plan it was noted that the organization did not have infection control goals so did not include Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed with the owner present. Observed in Data Session. During the Data session discussion and review of the Infection Control plan it was noted that the organization did not have infection control goals so did not include Limiting unprotected exposure to pathogens. This was confirmed with the owner present.

Observed in Data Session. During the Data session discussion and review of the Infection Control plan it was noted that the organization had not developed an influenza vaccination program and had not educated staff about at a minimum the influenza vaccine, non vaccine control and prevention measures and the diagnosis, transmission and impact of influenza. This was confirmed with the owner.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the organization had not planned care. For example in records RRBR#1 and #2 there was no documentation of a plan of care. No goals or interventions, the screen was blank. This was confirmed with the owner present.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services it was noted that an assessment was not documented. For example, in record RRBR#2 there was no documentation of a bereavement assessment after the patient death, the form was blank. This was confirmed with the owner present.

Observed in Record Review. In 1 of 3 patient records reviewed, that included aide services it was noted that the hospice aide supervision was not done every 14 days. For example, in record RRHV#3 the RN documented aide supervision after 16 days. This was confirmed with the administrator and nurse present.

Observed in HR File Review. In 3 of 10 HR files reviewed, it was noted that the LPN and Volunteer Coordinator/Volunteer was not initially assessed for EM procedures. Also, it was noted that the staff competency not assessed as part of orientation. For example, the Volunteer Coordinator/Volunteer and the Volunteer files did not include initially assessed competencies. This was confirmed with the Office Manager present.

Observed in Infection Control Tracer. In 3 of 3 home visits conducted, it was noted that the organization did not provide the patient with an individualized emergency plan. For example, during RRHV#1 and RRHV#3 the patient did not have a binder/folder in the home. The LPN present stated that he was aware the patient did not receive a binder and he brought one to the visit to provide to the patient and caregiver. During RRHV#2 the patient's binder in the home did not include a documented emergency preparedness plan. The owner was present at visits and on discussion with the owner she stated that the organization did not have a process for documenting an individualized EM plan.

Observed in HR File Review. In 2 of 10 HR files reviewed, it was noted that the organization had not obtained a criminal background check on the Volunteer Coordinator/Volunteer staff member. This staff had been been working for over 7 months. For example, another Volunteer's record included a criminal background check dated 5 years and 2 weeks before the date of volunteer employment and it stated that it was good for 5 years. This was confirmed with the Office Manager present.

Observed in Record Review. In 4 of 5 patient records reviewed, the surveyor observed that neither the IDG minutes nor other documentation in the record reflected an evaluation of the movement toward established goals. For example the POC had opened up problems and assigned target dates, but had not documented any progress in visit notes or IDG minutes. This included but not limited to pain, diabetes, and new medications.

Observed in Record Review. In 4 of 5 patient records reviewed, the surveyor noted that the organization social worker had not conducted visits according to the plan of care. This issue was discussed and confirmed with leadership.