Every finding on record at Mountain States Health Alliance

Upon patient record review 1 of 19 (Patient #7) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7: There was not evidence of a spiritual assessment.

Upon patient record review, 14 of 19 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) 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 Patients: #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14: The medication profile indicated Comfort Pak without medication names, or instructions for the administration of the medications. (Corrected on site) Patients: #1,#2,#3,#4,#5,#7,#8,#9,#10,#11,#12,#13,#14: The medication profile indicated Oxygen 2-5L prn without evidence of a route. (Corrected on site) Upon home visits, the following was identified: Patient #2: The medication profile indicated Nystatin 200000 take 10 ml, the POC indicated 100000 take 5 ml, and the bottle shows 100000 take 10ml. The patient was following the bottle. (Corrected on site) Patient #3: The medication profile indicated Albuterol, Decadron, Prilosec, Zofran, Oxycodone, Senokot, and Zanaflex. The patients spouse said she has not taken these medications in more than 2 weeks. (Corrected on site) Patient #4: Metoprolol was in home and not on medication profile. (Corrected on site)

Upon patient record review, 13 of 19 (Patients #1,#2,#3,#4,#5,#7,#8,#9,#10,#11,#12,#13,#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 medications and treatments. Patients: #1,#2,#3,#4,#5,#7,#8,#9,#10,#11,#12,#13,#14: The plan of care indicated Oxygen 2-5L prn without evidence of a route. (Corrected on site)

Upon patient record review 1 of 19 (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #3: The record indicated that on 08/30/2024 the patient refused vital signs due to pain. No pain scale was documented. There was not evidence the aide communicated the pain to the RN. The Aide care plan indicated the aide is to report pain > 6/10.

Upon personnel record review, 1 of 14 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel File #1: There was not evidence that the administrator has a BS degree as required by the job description.