Every finding on record at Elevation Hospice of Utah, LLC

Upon personnel record review, 2 of 19 (Personnel #11,13) 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 Personnel #11, 13: No documented evidence of orientation to Emergency Preparedness in files at time of survey

Upon patient record review, 1 of 19 (Patient #2) 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 #2: Patient observed to have indwelling Foley catheter during home visit. There is no order for Foley catheter at all.

Upon patient record review, 1 of 19 (Patient #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 #3: SOC 6/28/23. Initial Comprehensive assessment includes "potential condom cath". Initial POC includes catheter supplies under DME. No further reference or explanation if condom cath used.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2 - 10/17/23 SN Visit note that patient requires a urinary catheter. There is no reference to updated IDG and/or orders/PGI.

Upon client record review, 6 of 19 (Patient #1, 2, 3, 4, 8, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Initial POC 8/2/23-10/31/23 SC frequency 1m1 but 8/4/23 IDG POC frequency updated to SC 5m1, 3m1, 4m1. SC made 1 visit 9/12/23 in September when 3 ordered. There was no additional update for SC. Patient #2: SN freq 2/wk Only 1 visit week of Oct 1st and Oct 8th. MSW initially 1m1. SW saw patient weekly. Patient #3 7/13/23 Order for PT eval fall prevention. 4 visits subsequent visits were made without orders. Patient #4 Recert POC 9/1-10/30/23 has MSW frequency of 2m2. Patient was seen 4x in September and 4x in October. Patient #8 Effective 10/1/23, MSW 4m1,1m1. Patient was seen only 2 visits in October. Patient #9 Effective 10/1/23 MSW 2m1. The only visit documented is 10/3/23.

Upon patient record review 2 of 19 (Patient #2, 11) 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 #2: 8/4/23 Aide Frequency 3wk12, 1wk1. Week of Aug 6: 2 visits. Week of Aug 20: 1 visit. Week of Aug 27: no visits. Week of Sept 3: 2 visits. Week of Sept 25: 1 visit. Week of Oct 1, 2 visits. Week of Sept 25: 1 visit. 08/10/23 Aide Care plan Report assigns nail care weekly and shave and perineal care every visit. Nail care performed more than wkly: 10/30, 10/31, 11/1, 11/2, 11/3/23, 10/31, 11/1/23. 11/1/23 documented shave not required and perineal care not required. Also, patient #2 has indwelling Foley catheter observed during patient visit. Observed Aide empty Foley catheter drainage bag. Inquired to Aide if he performs catheter care and he responded that he does. Inquired if written assignment includes catheter care and he responded he thinks so. There is no assigned task for catheter care and no mention of Foley catheter on Aide assignment sheet. Patient # 11: Aide assigned nail care weekly. Performed 10/23, 10/24, 10/27/23.

Upon personnel record review, 2 of 15 (Personnel #11, 13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #11 and #13 did not have documented evidence of orientation in hospice philosophy.

Upon personnel record review, 1 of 15 (Personnel #13) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #13 did not have evidence of an orientation to the specific job duties. PT had provided visits to one patient.

Upon personnel record review, 1 of 15 (Personnel #13) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #13: no evidence of a competency for PT.