Every finding on record at Mountain View Hospice, LLC

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2 Aide visit note dated 1/9/25 stated there was a new wound on the back of the patients left leg and that RN was present at visit and notified of wound. There was no record of wound documented in the patient record by the RN to date. Corrected on site.

Upon patient record review, 3 of 14 (Patient #2,3,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2 Orders dated 11/25/24 for Xarelto daily, however no bleeding precautions in place. Corrected on site. Patient #3 Orders dated 12/12/24 for Warfarin daily, however no bleeding precautions in place. Corrected on site. Patient #9 Orders dated 1/9/25 for Eliquis twice daily, however no bleeding precautions in place. Corrected on site.

Upon patient record review, 6 of 14 (Patient #1,3,6,7,8,9) 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 #1 Aide care plan dated 12/2/24 states patient utilizes wheelchair for mobility, however there are no orders for the DME in place. Corrected on site. Patient #3 Nurse note on 12/12/24 states patient utilizes walker for mobility, however there are no orders for the DME in place. Corrected on site. Patient #6 Nurse note on 12/30/24 and 1/11/25 states patient utilizes walker and wheelchair for mobility, however there are no orders for the DME in place. Corrected on site. Patient #7 Nurse note on 8/3/24 states patient utilizes walker for mobility, however there are no orders for the DME in place. Corrected on site. Patient #8 CTI dated 1/3/25 states patient utilizes walker and wheelchair for mobility, however there are no orders for the DME in place. Corrected on site. Patient #9 Nurse note on 1/9/25 states patient utilizes Oxygen, however there are no orders for the DME in place. Corrected on site.

Upon patient record review 1 of 14 (Patient #2) 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 #2 Aide visit was completed 11/26/24 and per frequency orders, an additional visit was due by 11/30/24 and there was no documentation of the missed visit. Corrected on site.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon review, the total for use of volunteers is 2.4% of the total patient care hours of all paid hospice employees and contract personnel for 2024.

Upon patient record review, 2 of 11 (Patient # 1,5 ) 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. Patient 1: Benadryl on med profile without a route. Humalog U-100 on med profile without dosage/sliding scale. Patient 5: Gabapentin and Norco on the med profile without a route.

Upon patient record review, 2 of 11 (Patient #1,5) 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 medications and treatments. Patient #1: Order written as Bendadryl 25 mg 1 tab qhs for sleep. No evidence of a route. Humalog U-100 sq take as needed for uncontrolled blood sugar. No evidence of dosing/sliding scale. Patient #5: Order written as Gabapentin 300 mg cap 1 tid. Norco 7.5-325 mg take 1 tablet q 4 hrs prn pain. No evidence of route.

Upon client record review, 3 of 11 (Patient #1, 5, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SW frequency starting 1/27/22 1 visit q 2 weeks. Visits performed 1/31/22 and then 2/10 (less than Q2 weeks) and then next visit was 3/2 (greater than Q2 weeks). No evidence of missed visit or change in frequency order. Patient #5 SW frequency starting 6/10/21 1 visit q 2 weeks. Visits performed on 9/15/21 then not again until 10/6/21 (greater than Q2 weeks). Visit made 11/17/21 and then not again until 12/28/21 (greater than Q2 weeks). No evidence of missed visit documentation or change in frequency order. Patient #8 SW frequency effective 12/18/20 1visit q 4 weeks, 6/14/21 prn x1, 2/25/21 prn x1. Visits performed 12/17/20, 1/7/21, 2/8/21, 2/25/21, 3/23/21, 4/27/21, 5/17/21, 5/28/21, 6/11/21. No evidence of orders for additional visits.

Upon patient record review 2 of 11 (Patient # 7, 9) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #7: HHA ordered 10/2/20 2xw. No evidence of missed visit or order for 10/6/20. Patient #9: HHA order 9/20/21 2xw. Aide made one visit the week of 2/27/22. No evidence of missed visit documentation.