Every finding on record at Jireh Healthcare Services LLC

Observed in Tracer Activities. During the Volunteer Program discussion with the DON/Administrator/Volunteer Coordinator it was noted that there had not been recruitment activity or retention activity documented for 2022, 2023, or 2024. The organization stated that they had put up an ad for volunteers on Indeed and Vegas Healthcare Social Media 2 days ago and stated that in the past they have provided lunch and gas cards for the volunteers. However there was no documentation of the activities discussed.

Observed in HR File Review. During review of the Administrator/DON/Volunteer Coordinator HR file it was noted that the organization had not assessed and documented competencies annually per their policy. For example, the Volunteer Coordinator had documented annual competencies for 2022, 2023, 2024 however the 2023 competency dated 8/25/23 did not have an observer signature, only the Volunteer Coordinator. Also, there were no documented competencies for the Director of Nursing for 2022, 2023, 2024. This was discussed with the DON.

Observed in Record Review. In 3 of 7 record reviews, surveyor noted that the goals for plan of care were not specific with a measurable outcome and appropriate timeframe for goal attainment. For example, in RRHV#1, for problem of pain the goal stated will keep pain below SIT level, for diabetes management the goal stated patient will avoid hypoglycemic episodes. In RRNHV#1 for problem of pain the goal stated keep pain below SIT level for comfort. In RRNHV#5 for problem for constipation the goal stated facilitate bowel elimination and comfort. This was reviewed with the Administrator/Director of Nursing.

Observed in Record Review. In 1of 7 record reviews, surveyor observed that the IDG team failed to review and revise the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. For example, in RRHV#1, 28 calendars days had passed between IDG plan of care review and revision. This was verified with the Director of Nursing/Administrator.

Observed in Patient Home. In 2 of 3 home visits, surveyor observed that the nurse donned gloves to assess patients' skin and take patients' vital signs for BP, pulse, and temperature, however, the nurse did not remove gloves after providing care and proceeded to clean the equipment used and placed the cleaned equipment back into the bag using the same gloves. This was reviewed with the Director of Nursing/Administrator.

Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who also serves as Volunteer Coordinator, it was noted that there has not been an active volunteer program and, therefore, no recruitment activity for years 2022, 2023, an 2024. This was verified by the Director of Nursing/Administrator.

Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who serves as the Volunteer Coordinator, surveyor noted that the hospice had not had an active volunteer program since 2021. Therefore, there was no cost savings documentation. This was verified by the Director of Nursing/Administrator.

Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who serves as the Volunteer Coordinator, surveyor noted that noted that there has not been an active volunteer program for years 2022, 2023, an 2024, therefor, the organization had not achieved at least a 5 % cost savings through the use of volunteers. This was verified by the Director of Nursing/Administrator.

Observed in Tracer Activities. During the Volunteer Program discussion with the CEO and Administrator/Director of Nursing, surveyor noted that the organization did not implement volunteer program resulting in a condition level deficiency.

Observed in HR File Review. During the Competency Review Session, in 2 of 10 HR files reviewed, surveyor noted that the organization had not assessed and documented competencies annually per their policy. For example, the Volunteer Coordinator and Director of Nursing did not have annual competencies for 2022, 2023, and 2024. This was verified by the Administrator/Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits, during review of the medication reconciliation process performed by the nurse at the request of the surveyor, surveyor noted the frequency for the medication Albuterol Sulfate solution on the MAR was written to administer every 6 hours as needed; however, the frequency on the medication container was written to administer every 8 hours as needed. This was reviewed with the Director of Nursing/Administrator.

Observed in Patient Home. During review of the contract for DME, the surveyor observed that the leaders had not communication of the expectations for providing emergency backup oxygen for patients on oxygen. This was evidenced by in 3 of 3 home visits, surveyor observed that patients were utilizing oxygen via O2 concentrators, however, there were no back up oxygen tanks present in either of the patients' homes. This was verified with the Administrator/Director of Nursing.

Observed in Record Review. During RR#1 it was noted an order for Tylenol every 4 hours PRN pain and Oxycodone every 4 hours PRN pain. The medication profile direction did not document when to take the different pain medications.

Observed in Record Review. In 7 of 11 patient records reviewed, During RR#1, it was noted an RN did not visit the hospice patient every 15 days to conduct an assessment. The last RN assessment visit documentation was the middle of November 2021 with no RN documentation to date. SN visits in December 2021 and January 2022 to date were performed by an LPN. During HV#2 record review it was noted the last RN did not visit the patient at least once every 15 days to conduct an assessment. The record lacked documentation of RN assessment visits for 22 days to date, from the middle of January 2022. During RR#2 it was noted an RN did not visit the hospice patient every 15 days to conduct an assessment. The last RN assessment was 32 days to date with SN visits from the LPN. The last RN assessment visit documentation was the beginning of January 2022. During RR#3 it was noted an RN did not visit the hospice patient every 15 days to conduct an assessment. The last RN assessment visit documentation was the beginning of January 2022, 30 days to date. The SN visits were performed by an LPN. During RR#4 it was noted the RN did not visit the patient at least every 15 days for an assessment. The last RN assessment was the end of December 2021, 36 days to the beginning of February 2022. The SN visits were performed by an LPN. During RR#6 it was noted an RN assessment the end of April 2021. The next RN assessment visit was documented the end of August 2021. The SN visits were performed by an LPN. RN assessment visits resumed in September 2021. Observed in Record Review. In 11 of 11 patient records reviewed, During review of HV#1-3 and RR#1-8, it was noted lack of documentation included information about the patient’s progress toward desired outcomes and a reassessments of the patient’s response to care. Each goal in all records was documented that the goals would be accomplished in 14 days. During each IDG, the goals were updated to be accomplished at the next IDG e.g. in 14 days. Outcomes were documented as controlled at each IDG with the date changing to the date of each IDG. Limited goals were documented as closed. Response to care was not evident in IDG notes or the visit notes. Observed in Record Review. During RR#4 it was noted the IDG/POC was not changed to reflect changes in the patient condition and care. The following changes were not discussed by the IDG with changes made to the POC: the end of January an order for eye drops was added to the med profile, no update during IDG. The two nursing summaries in January were identical and were identical to the RN visit completed the end of December. A comm note in December noted a report that the patient was to be evicted from their residence. The comm note indicated the MSW would be notified. The documentation lacked any update to the IDG/POC on this issue. According to the DPCS this was an inaccurate report that the patient was to be evicted. Another comm note the end of October 2021 documented the patient had an issue with his medication for anxiety. This information was not communicated to the IDG

Observed in Record Review. During HV#2 record review it was noted at the IDG meeting the middle of January 2022 the RN summary documented the patient complained of mild shortness of breath with positive COVID-19 test. New medication orders are included on the IDG note and COVID-19 retesting. An order for oxygen therapy at 3L/min PRN SOB was added to the medication profile. The summary also included Observe safety and infection precaution measures and protocol. Monitor for any progress on infection and respiratory problems. The POC was not updated to include assessment, interventions and goals for the respiratory deficit identified.

Observed in Record Review. In 2 of 11 patient records reviewed, who have aide services. During HV#2 record review it was noted on a comm note the SNF where the patient resides has refused hospice aide visits at this time due to the patient being placed in isolation. The IDG/POC lacked an update to the change in the aide service frequency of visits. Visits resumed the beginning of February 2022. During RR#8, it was noted the aide frequency of visits was not on the POC. The aide service started the beginning of April 2021 and was discontinued the last week of April 2021.

Observed in Record Review. In 2 of 11 patient records reviewed, During HV#1 it was noted the patient supplies and DME included a walker, hospital bed, wheelchair, shower bench, chux, and incontinent pads. The POC only included the hospital bed with half rails. During HV#2 it was noted the patient supplies and DME not included on the POC were the walker, chux, diapers, SEHB. The POC included the APP mattress.

Observed in Record Review. In 2 of 11 patient records reviewed, During HV#1 record review it was noted, although the IDG met at least every 15 days, the IDG RN summary was not updated the middle of December 2021 to reflect the change in condition documented in a comm note 7 days prior to the IDG meeting that documented the patient was orally pocketing food per the facility staff. The diet was changed from a regular diet to puree in the intervention section of the POC. During RR#7, it was noted on a comm log the patient was tested and was positive for COVID-19 with respiratory symptoms. Medications for the new dx were added to the medication profile. The IDG note 5 days later lacked documentation of the new dx and lacked added assessment, interventions and outcomes related to the change in condition.

Observed in Record Review. In 2 of 9 patient records reviewed, who were receiving aide services. During RR#3 it was noted the hospice aide visits were not provided according to hospice plan of care. The visit frequency order for the aide was 5x/week. During the certification period the patient received 4 visits in 4 of the weeks starting the beginning of December to date. The record lacked documentation to indicate the reason for the frequency changes without notification to the IDG. During HV#1 record review it was noted the hospice aide frequency order was 5x/week during first certification. There were two missed visits, one in December 2021 and one in January 2022 without documentation of the reason for the missed visits.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV#1 it was noted the aide donned gloves to take vital signs for temperature, BP and pulse. The aide did not remove her gloves after providing care, disinfected the equipment used and placed the clean equipment back into the bag with the same gloves on.

Observed in Individual Tracer. In 4 of 11 patient records reviewed, who had orders for hospice aide care. During HV#1 it was noted the hospice aide assignment form indicated check vital signs every visit. The assignment lacked direction to the aide on vital sign parameters reportable to the SN. During HV#2 record review it was noted an order for oxygen therapy initiated in January 2022 was not updated on the hospice aide assignment form. In addition in HV#2 record review it was noted vital signs were not checked as a task for the aide to perform but there is direction from the SN when to call if vitals outside of parameters established. During RR#3 it was noted the aide assignment form lacked the oxygen order initiated during the RN comprehensive assessment. During RR#8 it was noted the hospice aide assignment form indicated check vital signs every visit. The assignment lacked direction to the aide on vital sign parameters reportable to the SN.

Observed in Record Review. In 1 of 10 patient records reviewed, who received hospice aide visits. During HV#1 record review it was noted the RN did not provide supervisory aide visits every 14 days. There was one supervisory visit documented in December 2021 and one in January 2022.

Observed in HR File Review. During HR#9 file review it was noted competency assessments had not documented since hire in 2014.