Every finding on record at Moniker Hospice Services of Salt Lake City, Inc.

Based on interview and record review, it was determined that the hospice did not ensure that 3 out of 4 hospice aides completed a competency evaluation before providing care to patients. (Employee identifiers: 2, 3 and 5) Findings include: The surveyor requested a list of hospice employees and selected a sample of employee records to review. There was no evidence that employees 2, 3 and 5 had successfully completed an aide competency evaluation prior to providing care to patients. On 4/13/2022 at 3:30 PM, an interview was conducted with the agency administrator (ADM). Evidence of aide's initial competency evaluations was requested for a third time. The ADM said he would get the information to the survey staff by end of the day. No evidence of the aide's initial competency evaluation was received. The information was requested on 4/11/2022 at 3:45 PM, 4/13/2022 at 1:05 PM and during the exit interview on 4/13/2022 at 3:30 PM

Based on observation, interview, and record review, it was determined the governing body/administrator did not assume full legal authority and responsibility for the management of the hospice. Specifically, the governing body/administrator did not insure paperwork was submitted to the Utah Department of Health timely after a change in ownership occurred. Findings include: On 4/11/2022 at 9:00 AM, an attempt was made to enter Silverado Hospice for survey. The surveyor found the door to be locked. The surveyor questioned other entities that worked in the same building as Silverado Hospice. The other entity reported to the surveyor that Silverado Hospice had not worked out of that office for quite some time. On 4/11/2022 at approximately 9:15 AM, a telephone call was placed to the number on file for Silverado Hospice. The employee who answered the phone, identified the hospice agency as Moniker Hospice (formerly Silverado Hospice) and stated the agency worked out of a sister facility and provided a new address. Furthermore, the employee stated that Moniker Hospice did not have an administrator and stated the administrator for the sister facility was providing over site for Moniker Hospice. On 4/11/2022 at 9:48 AM, a call was placed to the administer of the sister facility. The administrator stated Silverado Hospice was purchased in July 2021 and was not aware the change of ownership (CHOW) had not been completed

Based on interview and record review, it was determined the hospice interdisciplinary group (IDG) did not routinely document that they had reviewed the ability of the patient and/or family to safely administer drugs to the patient in his or her home for 4 of 8 active patients. (Patient identifiers: 3, 4, 6 and 8.) Findings include: A review of the medical records for patients 3, 4, 6 and 8 was completed from 4/11/2022 through 4/13/2022. Four of the eight medical records had no documented evidence the IDG had reviewed the ability of the patient and/or family to safely administer drugs to the patient in his or her home. On 4/13/2022 at approximately 3:00 PM, and interview was conducted with the administrative assistant and the director of nursing related to the IDG review of the ability of a patient/family to safely administer drug to the patient in his or her home. The administrative assistant and the director of nursing was unable to provide documented evidence that the IDG had reviewed the ability of the patient/family to safely administer medications to the patient in his or her home.