Every finding on record at Liahona, Inc.

Based on observation, interview and record review, it was determined that for 1 of 4 home visit observations, that agency staff did not clean/disinfect reusable medical equipment after patient cares and placed reusable equipment directly on top of the bed without a barrier. --- 1. On 12/14/2023 at 10:10 AM, a register nurse (RN) was observed while providing care to patient 18. The RN checked patients vital signs using a pulse oximeter, thermometer, electronic wrist blood pressure cuff, a stethoscope and a blood pressure cuff. The RN did not clean/disinfect any of the equipment used before placing the equipment back in the reusable equipment containers. After using each piece of equipment, the RN placed all equipment directly on the patients bed. No barrier was used. RN then returned all equipment directly into medical bag, contaminating all content . An interview was conducted on 12/14/2023 at 2:00 PM, with the RN. When asked how often she cleaned her equipment she stated I keep Clorox wipes in my car and do it at the end of my shift. When asked if she cleans/disinfects equipment between patients she stated yes, I do that in my car also and use alcohol wipes. 2. On 12/18/2023 at 9:50 am, an interview was conducted with the regional clinical director (RCD). When asked how often medical equipment should be cleaned/disinfected, she stated that staff should be cleaning equipment between patients and following policy. 3. The agency policy related to bag techniques was reviewed. It was documented in the policy, "When the visit is completed reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water, hands are washed, and equipment and supplies are returned to the bag ..."

Based on interview and record review, it was determined the hospice agency failed to meet the Condition of Participation for Organizational Environment. Specifically, the agency was operating two branches that were not approved by Medicare or the State Agency. --- Findings include: The hospice agency failed to ensure multiple hospice locations were approved by Medicare and the State Agency prior to providing services. (Refer to tag L656)

Based on interview and record review, it was determined the hospice agency did not ensure the a hospice location was approved by Medicare and the State Agency prior to providing services. --- Findings include: An entrance interview was conducted with the Regional Clinical Director (RCD) on 12/13/2023 at approximately 10:05 AM, the RCD was asked if the agency had any branches. The RCD stated that there were branches in the Salt Lake City area and the Layton area. The RCD was asked if the branches were operating under the CCN (a numbering system for Medicare participating providers) for the main office located in Orem. The RCD stated, "Yes". The RCD was asked when the Interdisciplinary Group Met. The RCD stated that the Layton office met every other Thursday at 9:30 AM, the Salt Lake office met every other Thursday at 9:30 AM and the Utah County office met every other Thursday at 8:00 AM. Business cards for the RCD and the Orem Office Manager (OM) were obtained. Locations on the business card included Utah County; Box Elder, Davis and Weber Counties; as well as Salt Lake County. Phone numbers for each location were listed. A telephone interview was conducted with the Administrator (ADM) on 12/13/2023 at approximately 11:45 AM. The ADM stated that each location was staffed with a Director of Nursing (DON), receptionist and an office manager. (NOTE: The ADM stated that the Salt Lake location was only for the agency home health service.) A review of the agency web site was conducted on 12/13/2023. The web site documented there was "Hospice Care in Utah, Salt Lake, Davis and Weber Counties." A list of personnel for each office was requested during the entrance conference. The Salt Lake City Worker Roster had 23 workers including four Medical Directors (MD), one Nurse Practitioner (NP), ten Registered Nurses (RNs) and eight certified nurse aides (CNAs). The Davis and Weber County Worker Roster had fourteen workers including one NP, two Licensed Social Workers (LSWs), seven RNs, one Licensed Vocational Nurse (LVN) and four CNAs. The main office had 38 workers. On 12/13/2023 at 1:41 PM, an e-mail was received from the RCD. The RCD documented, "Also-to clarify a couple of things from our earlier conversation, The Murray office is the Location of our HH (Home Health) [name redacted] license. I guess that doesn't really related to this survey? My Clinical Supervisor (I call her a DON but I am technically the DON for our HH and Hospice) [name redacted] is in that office. For Hospice services, this is our 'headquarters' and we see patients throughout the Wasatch Front basically." Review of the State Agency records for Utah Hospice were reviewed. There was no documentation that Utah Hospice had notified the State Agency that there were branches in Salt Lake City or Layton. The review of records shows no evidence of Medicare certification approval for these locations.