Every finding on record at Hospice of Mesilla Valley, LLC

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency was unable to provide a drill or experienced emergency summary.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 8: The medical record contained an election form and consents signed by the patient's nephew. There was no evidence the nephew had legal authority to make decisions for the patient. Upon observation during home visit, the patient was alert and oriented and accompanied by alert and oriented spouse.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 13: There was documentation of a request for daily visits and concern of overmedication with no documentation of change in frequencies to meet needs or discussion with daughter regarding increase in morphine as requested by the facility staff.

Upon patient record review 2 of 14 (Patients #4,#7) 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: The medical record contained a comprehensive spiritual care assessment completed 6/2/23 with start of care date of 5/25/23. Patient 7: The medical record contained a comprehensive spiritual care assessment completed 6/20/23 with start of care date 6/14/23. POC compliance date 6/16/23.

Upon patient record review, 1 of 14 (Patient #7) 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. • Drug therapy currently associated with laboratory monitoring Patient 7: The medical record contained nursing documentation upon recertification visit 8/22/23 identifying patient use of over the counter miralax for bowel management. There was no evidence of the miralax listed on the medication profile. Corrected on site.

Upon patient record review, 2 of 14 (Patients #3,#7) 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 3: The medical record contained nursing documentation upon admission identifying patient use of an indwelling catheter and CPAP. There was no evidence of ordered for catheter size and maintenance, and CPAP parameters. Patient 7: The medical record contained nursing documentation upon recertification visit 8/22/23 identifying patient use of over the counter miralax for bowel management. There was no evidence of an order for miralax. Corrected on site.

Upon client record review, 3 of 14 (Patients #2,#5,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an ordered spiritual care visit frequency of two visits in August 2023. There was only evidence of one spiritual care visit completed in August. Patient 5: The medical record contained an ordered spiritual care visit frequency of once weekly. There was no evidence of spiritual care visits completed the weeks of 7/2/23, 7/9/23, 7/16/23, and 7/23/23. Patient 10: The medical record contained an ordered social work frequency of once monthly. There was evidence of two scheduled social work visits completed in June on 6/15/23 and 6/30/23.

Upon patient record review 4 of 14 (Patients #2,#5,#6,#9) 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 Patient 2: The medical record contained an ordered aide frequency of three times weekly. There was only evidence of one visit completed the week of 8/20/23. Patient 5: The medical record contained an ordered aide frequency of twice weekly. There was only evidence of one visit completed the week of 7/2/23. Patient 6: The medical record contained an ordered aide frequency of three times weekly. There was only evidence of one visit completed the week of 8/20/23. Patient 9: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of visits completed the week of 8/20/23.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 11: There was no evidence of orientation to hospice philosophy.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 11: There was no evidence of orientation.

Upon patient client record review, 2 of 14 (Patient #13, #14) did not evidence that each patient record contains physician orders. Patients 13,14: There was no evidence of an order to discharge patient per agency discharge policy.

Upon patient client record review, 2 of 14 (Patients #1,#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 1: The medical record contained unclear reason for missed visit documentation 7/7/23 and 8/4/23. The provided template for date information, discipline, and reason for missed visit was not completed. Patient 8: The medical record contained an incomplete EMS DNR form signed by the physician but not signed by patient or representative. Agency investigation identified patient is a full code.