Every finding on record at Luna Del Valle Healthcare Services

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) 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 #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence of the appropriate documentation for release of confidential information. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 1 of 20 (Patient #6) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon patient record review, 8 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: MSW frequency is 1-2 prn. There is no baseline frequency. Patient #2: SC 1mo3; 2mo3 PRN. There are too many PRN's ordered. Patient #3: SN 1wk13 10/22-1/18/26. SN 2wk14 PRN 10/22-1/18/26. MSW 1wk1; 1-2PRN. SC 1wk13 PRN change in condition 10/27-1/18/26. There are too many PRN's ordered. Patient #4: SN 2w14; 10/29-1/26 and 2wk14 PRN. MSW 1wk1 10/29-11/01/25. MSW 1m2 PRN 11/3-12/31. There are too many PRN's ordered. Patient #5: SN 2w14; SN 2wk14 PRN both for 10/9/25-1/6/26. SC 1wk1 10/9-10/11. SC 2m4 PRN. There are too many PRN's ordered. Patient #6: SN 2wk14 and 2wk14 PRN 11/7/25-2/4/26. SC 2mo4 11/20-2/4/26; SC 2m4 PRN. There are too many PRN's ordered. Patient #7: SN 2wk14 and 2wk14 PRN 11/6/25-2/3/26. There are too many PRN's ordered. Patient #8: SN 2wk14 and 2wk14 PRN 11/5-2/2/26; SC 1wk1 for 11/5-11/8; 2m4 PRN 11/5-2/2/26. There are too many PRN's ordered.

Upon patient record review, 3 of 20 (Patient #2, 5, 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 #2: POC order for Oxygen is Oxygen 6L intranasally daily, hypoxemia. Start 11/5/25. This is an incomplete order. Patient #5: POC order for Oxygen 2L intranasally daily, incomplete order. Patient #7: Oxygen 5L intranasally daily. Comprehensive assessment notes that patient supplements regular soft diet with enteral feedings. Jevity 1 carton 1.5 TID. Does not specify route. (Gastrostomy per 11/18/25 visit note).

Upon patient record review, 1 of 20 (Patient #14) 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 #14: Patient has a foley catheter there are no catheter supplies listed

Upon client record review, 1 of 20 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: 12/13/25 Patient called agency with complaint of knee pain. Requested (steroid) injection. Agency advised hospice does not provide that - to use cold compresses, and take her pain medication and then relax with left leg up. Patient verbalized understanding. No order obtained for compresses. In addition, the volunteer assessment completed on 10/24/25 with no order.

Upon patient record review 1 of 20 (Patient #5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #5: 10/24/25 Volunteer assessment and patient accepting of massage therapy. Agency unable to follow through as volunteer has not completed orientation due to family crisis.

Upon patient record review, 2 of 19 (Patient #1,2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: 11/19/25 and 11/26/25 addendum Hospice Aide Care Plan does not address oxygen and/or oxygen precautions. Patient has 2 LPM via NC prn. Patient #2: 11/05/23 Hospice Aide Care Plan has tasks frequency of 2 but Hospice Aide visit frequency is 1/wk.

Upon patient record review 6 of 20 (Patient #1,2, 6, 7, 8, 10 ) 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 #1: 10/20/25 Hospice Aide Care Plan says 2x/week. First order is 11/16/25. Updated care plan for 1x/week. First visit 11/19/25. Patient #2: 11/5/25 Hospice Aide 1/week. No visit documented week of 11/18/25. Follow up SV 12/3/25 note does not address missed visit. Patient #6: Patient admitted 11/7/25. Initial POC has Hospice Aide frequency 2wk14. Hospice Aide care plan completed. No visits provided thus far. Patient #7: Patient admitted 11/6/25. Hospice Aide 2wk14 start 11/6-2/3/25. Hospice Aide Care Plan 11/6/25. Another Hospice Aide Care Plan 11/11/25. The only visit provided was 11/17/25. Hospice Aide SV 11/17/25 with no mention that no visit provided prior to 11/17/25 Patient #8: Patient admitted 11/5/25. Hospice Aide Care plan and order 11/5/25 for Hospice Aide. Multiple orders written related to missed visits. 12/5 for 11/30-12/6 decrease Hospice Aide frequency to 0 POA declined 2nd attempt. There was no updated frequency for the following week when visits made 12/9 and 12/11/25. Patient #10: Patient admitted 10/19/24 with Hospice Aide frequency of 2/wk. Only 1 visit made week of 11/11/25.

Upon patient client record review, 1 of 20 (Patient #6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #6: Hospice Election/Consent/Acknowledgement electronically signed by the patient. Patient's primary diagnosis is Alzheimer's Disease.

Upon patient client record review, 1 of 20 (Patient #4) 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 #4: 12/11/25 visit note respiratory section states patient is dyspneic with walking> 20 ft, and with moderate exertion. Notes Oxygen in use and patient is on Oxygen 2L during visit. (not on Oxygen 12/5 or 12/9/25 visits). No order in POC for oxygen. Upon interview, agency reports patient is not on Oxygen.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Upon client record review, 1 of 20 (Patient #6) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #6: Patient with hospice diagnosis of Alzheimer's electronically signed consent/election of hospice form.

Based on record review and interviews, the facility failed to verify a licensure for 1 (S[staff]4) of 3 (S2-4) LPN’s (Licensed Practical Nurse) applicants. S4 was licensed as a CNA (Certified Nursing Assistant) but was working and seeing patients as an LPN. CNAs have a shorter term of education and are prepared to take VS (vital signs) including heart rate, blood pressure, pulse, and temperature. A CNA can help patients with bathing, dressing and getting in and out of bed. An LPN has additional education and training to assess and monitor patients for changes in their condition. This deficient practice could possibly lead to failure to recognize important changes in a patient's condition which could result in poor patient outcomes. --- The findings are:A. Record review of S4’s clinical employee file revealed S4 was hired in March 2024 with an active CNA license. S4 indicated on her initial application for employment that she was an LPN. On 08/14/24, S5 nonclinical completed an online check with Nursys (national database for verification of nurse licensure, discipline and practice privileges for disciplines including LPN’s and PN’s [Practical Nurse]) which showed a PN license active in the state of Kansas for S4. S4 was promoted to an LPN position on 08/14/2024 by S7 non-clinical, the former Director of Clinical Services (S7). B. Record review of the patient charts’ revealed that S4 conducted patient visits where she carried out complete assessments, monitored deterioration of status, performed wound care, and administered medications which is illegal for CNAs to conduct under the New Mexico State Nurse Practice ActC. During an interview with S1, clinical on 05/20/25 at 9:50 AM, S1 confirmed that CNAs do not perform patient assessments, that function is assigned to skilled nursing.D. During an interview with S5, non-clinical on 05/20/2025 at 2:00 PM, she acknowledged the responsibility for licensure verification. She stated the licenses of all staff are checked online every three months. S4 licensure was checked online in March 2024, August 2024, and December 2024. S5 reported in August 2024 the former director of clinical services reviewed “Nursys” report for S4 and made the decision to promote S4 to LPN. When S5 conducted a routine check of licensure in December 2024 she realized S4 did not have an active LPN license, but S4 did have an active CNA license. S5 then escalated the finding to S8 the administrator.

Upon patient record review, 1 of 11 (Patient #5) 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 5: The patient requires a walker, nebulizer, and oxygen for management or the terminal illness; however this DME does not appear on the patient's plan of care. (corrected onsite)

Upon patient record review, 7 of 11 (Patient #1, 2, 4, 6, 7, 8, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1, 2, 4, 7, 8: The hospice aide care plan indicates both a bed bath and a shower with chair is to be performed on every visit; this is a duplicate order and the aide is unable to determine which personal care task is appropriate on each visit. (corrected onsite) Patient 6: The hospice aide care plan indicates both a bed bath and a shower is to be performed on every visit; this is a duplicate order and the aide is unable to determine which personal care task is appropriate on each visit. (corrected onsite) Patient 9: The hospice aide care plan indicates a bed bath, a shower, and a shower with chair is to be performed on every visit; this is a duplicate order and the aide is unable to determine which personal care task is appropriate on each visit.