Every finding on record at Mountain Hospice, Inc.

Based on medical record review, observation, document review, and staff interview, the facility failed to ensure that an accurate drug profile was maintained in one (1) of fourteen (14) medical records reviewed (Patient #3). This failure has the potential to affect all patients receiving medication services through the facility. --- A medical record review was completed on 3/24/25. The medical record revealed there was no Synthroid on the current medication profile for Patient #3. An observation was completed on 3/25/25, at 8:45 a.m., with Staff #1 and Patient #3 during a home visit. During the observation, Staff #1 was reviewing Patient #3's medication and it was discovered that the patient has been taking a Synthroid 50 mcg once a day that was not on the active medication list. When the patient was asked about the medication they stated, "My doctor put me on it." Staff #1 asked Patient #3, "Didn't we discuss discontinuing the Synthroid?" The patient stated, "Yea but the doctor put me back on it." Staff stated, "we don't have that medication on our list. I will add it now and let them know at the office." A policy titled ";Patient Care Policies & Procedures" (Medication-Management), last revised 10/2018, was reviewed. The policy states in part, ";Policy...(5). A medication profile is maintained. For every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient's terminal illness. (6). The Medication profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements/remedies... (9). The Hospice monitors the medication dispensed to and used by the patient." An interview was conducted on March 25, 2025, at 10:35 a.m. with Staff #2. Staff #2 stated, ";Patient #3 was not on Synthroid at admission. Synthroid was not on the active medication list until today, 3/25/25."

Observed in Emergency Management Session. The organization had not updated their emergency management plan for 4 years. This was discussed with the DON.

Observed in Emergency Management Session. The organization had not developed a plan for obtaining food, water, medications and medical supplies during an emergency event. This was discussed with the DON.

Observed in Emergency Management Session. The organization had not developed a process for contacting emergency operations center to notify them of on duty staff that they were unable to reach. This was discussed with the DON.

Observed in Emergency Management Session. The organization's emergency plan did not included job responsibilities for staff and volunteers. This was discussed with the DON.

Observed in Emergency Management Session. The organization had not conducted any emergency drills in the last 3 years nor written an after action plan to review opportunities to improve their plan. This was discussed with the DON.

Observed in Record Review. In 1 of 5 active records reviewed, the RN failed to complete a comprehensive reassessment every two weeks as required by regulation and agency policy. This was discussed with the DON. (RR#9)

Observed in Record Review. In 13 of 13 patient records reviewed, The plans of care did not include measurable goals or individualized target dates as required by regulation and agency policy. The dates were all end of episode. This was discussed with the DON.

Observed in Record Review. In 2 of 3 patient records reviewed, for hospice aide services, in record #7 the hospice aide was ordered by the RN to start visits on a Wednesday. However the aide did not make a visit until the following Monday. In record #10, the aide was ordered on a Wednesday to make 5 visits a week. The aide made one visit the first week There was no documentation ad to why the visits were not made as ordered. This was discussed with the DON. (RR#7, RR#10)

Observed in Record Review. In 3 of 3 patient records reviewed, for hospice aides, the aides' care plans and frequencies included PRN visits. This was discussed with the DON.

Observed in Patient Home. In 2 of 3 resident records reviewed, for hospice aides providing care, the nursing supervisory visits in clinical record RR#7 and RR#9 were not conducted at least every 14 days as required by regulation on agency policy. This was discussed with the DON.

Observed in Document Review. The Governing Board / Leadership did not ensure that the following Conditions of Participation were not met as determined through observation,documentation and staff interviews. 418.113

Observed in Patient Home. In 2 of 3 home visits conducted, medications either in the home or on the agency MAR (medication administration record) did not match. For example at home visit #2, the MAR stated that the patient was on Lyrica and atropine eye drops, neither of these medications were found in the home. At home visit #3, the morphine listed on the MAR was not found in the home. This was discussed with the case managers and the DON.

Observed in Document Review. In 5 of 5 contracts reviewed, there was no documentation that the organization had conducted any regular oversight of their contracts to confirm that each was following the organization's written expectations. This was discussed with the DON.

Observed in Record Review. IN review of clinical record HV#1, the plan of care did not identify which provider of care - the agency staff or the facility staff - would be responsible for performing the tasks agreed upon and included in the plan of care as required by regulation and agency policy. This was discussed with the DON.