Every finding on record at Madrona Hospice Care Inc

Upon patient record review, 1 of 5 (Patient #2) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The Medication Profile included the following content: "Vitamin B12 sublingual tab 1000 mcg. One tab monthly. Inject 1000 mcg monthly." The Vitamin B12 is a monthly injection.

Upon patient record review, 1 of 5 (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:The 90-day SOC POC included the following content: "Vitamin B12 sublingual tab 1000 mcg. One tab monthly. Inject 1000 mcg monthly." The Vitamin B12 is a monthly injection.

Upon patient record review, 2 of 5 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: The RN SOC assessment reflected that the patient had a Wheel Chair. This DME was not included on 12/08/24 IDG POC. Patient #2: The RN SOC assessment reflected that the patient had a cane. This DME was not included on 12/08/24 IDG POC, nor the 90-day SOC POC.

Upon personnel record review, 1 of 11 (Personnel #7) did not contain evidence that an Aide Skills Competency assessment had been performed by the Aide with a patient, as per CMS-requirements: Personnel #7: An Aide Skills Competency assessment was conducted by an RN on 07/02/2024. However, the following tasks/skills were not evaluated for as required per CMS: 1) Communication Skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other Hospice staff; and 2) Reading and recording temperature, pulse, and respiration; were not evaluated for while the Aide was providing care/services to a patient or pseudo-patient. The evaluating RN documented "Verbal" as the method used to evaluate for these skills. The following subject areas, which may be evaluated through written examination, oral examination, or after observation of a Hospice Aide with a patient, had been left blank in the form's space, wherein the RN was to document if the Aide had successfully demonstrated competency: • Observation, reporting and documentation of patient status and the care or service furnished • Basic infection control procedures • Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor • Maintenance of a clean, safe, and healthy environment • Recognizing emergencies and knowledge of emergency procedures and their application • The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for the patient, his or her privacy and his or her property • Adequate nutrition and fluid intake

Upon patient record review, 1 of 5 (Patients #4) did not contain evidence that all entries were clear: Patient #4: A document within the clinical record entitled, "Discharge Live" included the following content: "Discharged on 09/27/24. Discharged to home/self-care. Reason for DC - Patient moved out of service area. Under 'Comments' section, "Patient/wife called 09/27/24. They would like to seek treatment for CHF, and no longer require Hospice services." This is unclear documentation.

Upon Inpatient contract review, 1 of 1 (Silver) did not contain content that required the inpatient facility to provide Hospice with a copy of the Discharge Summary at the time of inpatient discharge.

Upon personnel record review, 4 of 11 (Personnel #3, 4, 5, and 8) did not contain evidence of a Criminal Background Check (CBC) having been obtained on all contracted individuals who have direct patient care and access to patient records, in accordance with Nevada State requirements. All of these contracted direct patient care files had evidence of a CBC having been conducted prior to the provision of patient care. However, they did not demonstrate evidence of the conduct of the required Nevada State CBC version as follows: Under Nevada Revised Statutes (NRS) 449.176 through NRS 449.188, people who have been convicted of certain crimes may not work at certain long term care facilities or agencies. The discussion here concerns the requirements of NRS 449.176 through NRS 449.188 only, and is intended as a guide only. The complete statute is available at http://leg.state.nv.us/NRS/NRS-449.html Under NRS 449, you must conduct a fingerprint-based criminal history background check on each employee and each independent contractor if you are the administrator of, or you are licensed to operate, any of the following: • Agency to provide personal care services in the home • Agency to provide nursing in the home • Facility for intermediate care • Facility for skilled nursing • Residential facility for groups • Homes for individual residential care These background checks must be conducted through the Central Repository for Nevada Records of Criminal History, an agency of the Nevada Department of Public Safety, Records and Technology Division. Even if you use another agency to conduct a preliminary criminal history check, you must conduct a background check by submitting fingerprints to the Central Repository, as required by the statute and summarized here. If your business is not one of the five types of entities listed above then you may choose to voluntarily submit fingerprints under NRS 179A.210 to obtain criminal history information with each employee's consent, but you are not authorized to have the Department of Public Safety evaluate an individual's criminal history under NRS 449. NRS 449.123 applies to every employee or independent contractor, including the administrator and the person licensed to operate the agency or facility, regardless of whether the individual provides direct patient care. You must conduct the background check in addition to any other fingerprint-based criminal history background check that the individual may have already undergone, such as to obtain a professional license, including a nursing license or a long term care administrator license. (See Special Notices below.) The statute does not apply to a volunteer. The statute does not apply to an individual that is not hired by you or your licensed entity but rather is hired directly by a resident at your licensed entity.

Upon personnel record review, 4 of 11 (Personnel #6, 7, 9, 10) did not contain evidence of a Criminal Background Check (CBC) having been obtained in accordance with Nevada State requirements. All of these direct patient care employee files had evidence of a CBC having been conducted prior to the provision of patient care. However, they did not demonstrate evidence of the conduct of the required Nevada State CBC version as follows: Under Nevada Revised Statutes (NRS) 449.176 through NRS 449.188, people who have been convicted of certain crimes may not work at certain long term care facilities or agencies. The discussion here concerns the requirements of NRS 449.176 through NRS 449.188 only, and is intended as a guide only. The complete statute is available at http://leg.state.nv.us/NRS/NRS-449.html Under NRS 449, you must conduct a fingerprint-based criminal history background check on each employee and each independent contractor if you are the administrator of, or you are licensed to operate, any of the following: • Agency to provide personal care services in the home • Agency to provide nursing in the home • Facility for intermediate care • Facility for skilled nursing • Residential facility for groups • Homes for individual residential care These background checks must be conducted through the Central Repository for Nevada Records of Criminal History, an agency of the Nevada Department of Public Safety, Records and Technology Division. Even if you use another agency to conduct a preliminary criminal history check, you must conduct a background check by submitting fingerprints to the Central Repository, as required by the statute and summarized here. If your business is not one of the five types of entities listed above then you may choose to voluntarily submit fingerprints under NRS 179A.210 to obtain criminal history information with each employee's consent, but you are not authorized to have the Department of Public Safety evaluate an individual's criminal history under NRS 449. NRS 449.123 applies to every employee or independent contractor, including the administrator and the person licensed to operate the agency or facility, regardless of whether the individual provides direct patient care. You must conduct the background check in addition to any other fingerprint-based criminal history background check that the individual may have already undergone, such as to obtain a professional license, including a nursing license or a long term care administrator license. (See Special Notices below.) The statute does not apply to a volunteer. The statute does not apply to an individual that is not hired by you or your licensed entity but rather is hired directly by a resident at your licensed entity.