Every finding on record at Desert View Hospice, Inc

Upon personnel record review, 3 of 14 (Personnel #12, 13, 14) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon patient record review 2 of 14 (Patients #6,#8) 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 6: There was no evidence of a spiritual assessment completed by any discipline within 5 days. Spiritual care visits were later initiated and patient received regular scheduled visits in February, March and May of 2023. Patient 8: There was no evidence of a spiritual assessment completed by any discipline within 5 days. The initial spiritual assessment was completed 5/2/23 with a start of care 4/22/23.

Upon patient record review, 1 of 14 (Patient #1) 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 Patient 1: The medication profile contained a topical lidocaine with no area defined for administration and miralax powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 2 of 14 (Patients #6,#8) 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 6: The initial bereavement assessment was completed 10/4/22 with start of care 7/3/22. Patient 8: The initial bereavement assessment was completed 5/2/23 with start of care 4/22/23.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: There was no evidence of wound measurements and assessments in April and May.

Upon patient record review, 5 of 14 (Patients #3,#4,#6,#7,#8) 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 3: The medical record contained nursing documentation 3/22/23 identifying patient received social work visits and had problems with constipation and nutritional modifications requiring pureed diet and thickened liquids. There was no evidence of problems, goals, and interventions related to psychosocial needs, constipation and nutritional deficit included on the plan of care. Corrected on site. Patient 4: The patient's primary hospice diagnosis was heart failure. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included on the plan of care. Corrected on site. Patient 6: The patient's primary hospice diagnosis was heart failure. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient risk for skin impairment and patient received social work visits. There was no evidence of problems, goals, and interventions related to risk for skin impairment and psychosocial needs included on the plan of care. Corrected on site. Patient 8: The medical record contained evidence the patient received social work visits. There was no evidence of problems, goals, and interventions related to psychosocial needs included on the plan of care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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 medications and treatments. Patient 1: The medical record contained an order for topical lidocaine with no area identified for administration and miralax powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 7 of 14 (Patients #1,#3,#4,#5,#6,#7,#8) 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: The medical record contained nursing documentation 4/27/23 identifying patient use of a wheelchair and shower chair. There was no evidence of the wheelchair and shower chair included as DME in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 3/22/23 identifying patient use of a hospital bed, over the bed table, nebulizer, and suction machine. There was no evidence of the bed, table, nebulizer and suction included as DME in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a cane, walker, and shower chair. There was no evidence of the cane, walker, and shower chair included as DME in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 5/1/23 identifying patient use of a walker. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 4/6/23 identifying patient use of a hospital bed, air mattress, walker, wheelchair, and shower chair. There was no evidence of the bed, mattress, walker, wheelchair, and shower chair included as DME in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair and commode. There was no evidence of the wheelchair and commode included as DME in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, and shower chair. There was no evidence of the bed, table, and shower chair included as DME in the plan of care. Corrected on site.

Upon client record review, 3 of 14 (Patients #5,#6,#8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contained an ordered social work frequency of once monthly. There were 3 scheduled social work visits completed in April 2023. Patient 6: The medical record contained an ordered social work frequency of once monthly, nursing twice weekly, and no order for spiritual care. The medical record contained 2 scheduled social work visits in April 2023, 1 nursing visit the weeks of 4/2/23 and 4/9/23, and scheduled spiritual care visits 2/27/23, 3/29/23, and 5/1/23. Patient 8: The medical record contained an ordered nursing frequency of twice weekly. There were 3 scheduled nursing visits the weeks of 4/23/23.

Upon personnel record review, 3 of 14 (Personnel #12,#13,#14) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon patient record review, 6 of 14 (Patients #4,#5,#7,#11,#13,#14) 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 4: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 5: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 7: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 11: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 13: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 14: The medical director's narrative for admission only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary.

Upon patient record review, 2 of 14 (Patients #2,#13) did not have 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 2: The medical director's narrative for recertification 3/27/23 only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary. Patient 13: The medical director's narrative for recertification 8/4/22 only stated anticipated prognosis of 6 months or less. The narrative written on the CTI was the RN narrative from the assessment and was titled RN summary.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 8: The medical record contained an election form identifying the patient elected to receive the notification of hospice non-covered items. There was no evidence the patient received the form.

Upon patient client record review, 3 of 14 (Patients #3,#7,#8) 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 3: The plan of care frequency section did not include the ordered social work and spiritual care frequencies. Corrected on site. Patient 7: The plan of care frequency section stated nursing frequency was once weekly instead of the twice weekly ordered frequency. Corrected on site. Patient 8: The plan of care frequency section did not include the ordered social work and spiritual care frequencies. Corrected on site.

Upon inpatient contract review, 1 of 4 (Bradley Gardens GIP/respite contract) did not have evidence that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished.

Upon inpatient contract review, 1 of 4 (Bradley Gardens GIP/respite contract) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

Upon inpatient contract review, 1 of 4 (Bradley Gardens GIP/respite contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 4 (Bradley Gardens routine NF contract) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

Upon SNF/NF contract review, 1 of 4 (Bradley Gardens routine NF contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.