Every finding on record at Nevada Hospice Agency LLC

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The emergency communication plan did not contain evidence of alternate means of communication with federal, state, tribal, regional, and local emergency management agencies.

Upon patient record review, 1 of 14 (Patient #3) 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 #3) Upon review of the patient's medication profile reconciled with his medications at home, the patient's medication profile did not contain evidence of the following: a) Hydralazine 100 mg, 1 tab oral daily, b) Lantus 14 units, subcutaneous two times a day, 3) Polyethylene Glycol 17 grams daily as needed for constipation, 4)Losartan Potassium, 100 mg oral daily. Patient's spouse confirmed patient takes these medications daily.

Upon patient record review, 14 of 14 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient's # 1- 14) There was no evidence of documentation regarding scope for PRN visits for Nursing, MSW, and Chaplain on the patients' plan of care. PRN frequencies only are not acceptable and 18 PRN per discipline does not meet the specific patient and family needs.

Upon patient record review, 13 of 14 (Patients # 1, 2, 3, 4, 5, 7, 8, 9, 10, 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 equipment and supply needs. Patient #1) Patient's plan of care dated 9/21/23 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a hospital bed, overbed table, 02 concentrator, and wheelchair. Patient #2) Patient's plan of care dated 5/19/24 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a hospital bed, bed rails, and wheelchair. Patient #3) Patient's plan of care dated 7/30/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a walker, wheelchair, 02, overbed table. Patient #4) Patient's plan of care dated 3/4/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a walker. Patient #5) Patient's plan of care dated 6/3/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a wheeled walker, non-wheeled walker, and wheelchair. Patient #7) Patient's plan of care dated 3/7/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a bedside commode and walker. Patient #8) Patient's plan of care dated 3/13/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a walker and wheelchair. Patient #9) Patient's plan of care dated 4/17/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included bedrails, hospital bed, overbed table, 02 concentrator, and gel overlay. Patient #10) Patient's plan of care dated 7/9/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included an overbed table, 02 concentrator, and wheelchair. Patient #11) Patient's plan of care dated 7/9/25 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included an overbed table, 02 concentrator, 02 cylinder, and wheelchair. Patient #12) Patient's plan of care dated 11/7/23 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included bed rails, hospital bed, overbed table, 02 concentrator, and wheelchair. Patient #13) Patient's plan of care dated 7/12/24 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a shower chair. Patient #14) Patient's plan of care dated 8/12/24 did not contain patient equipment. The patient's equipment listed in the initial comprehensive assessment included a hospital bed, overbed table, 02 concentrator, and walker.

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. The 2024 annual cost savings report to the governing board reflected a 4% cost savings.

Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #5) The contracted OT did not have evidence of current licensure.

Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel # 5) Personnel file did not contain evidence of a criminal background check upon hire.

Upon personnel record review, 1 of 11 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel # 11) Personnel file did not contain evidence of a criminal background check upon hire.

Based on interview, record review, and policy review, the agency failed to ensure that medications listed on the hospice agency's medication list were the same medications listed on the nursing facility's medication list for two of 10 patients (Patient (P)4 and P1) whose medications were reviewed out of a total sample of 14. This had the potential to cause P4 and P1 to suffer adverse drug events.Findings include: --- 1. During a review of P4's "Physician's Orders" in P4's group home revealed P4 did not have an order for Adult Tussin Chest Congestion (a cough medication) 100 mg/5 ml (100 milligrams per 5 milliliters) oral liquid give 10 ml every four hours as needed.Review of P4's "Client Medication Sheet," dated for the certification period of 06/24/2025 to 09/21/2025 and provided by the agency, revealed P4 had an active order for Adult Tussin Chest Congestion 100 mg/5 ml oral liquid give 10 ml every four hours as needed.During an interview on 07/11/2025 at 11:40 AM, Registered Nurse (RN)1 stated, "I must have forgotten to mark this order as being discontinued on our paperwork in the office."2. During a review of P1's "Medication Sheet" of active orders for the month of July 2025, in P1's group home, it was revealed the patient was being given Metoprolol Tartrate (a blood pressure medication) 25 mg (milligram) half tablet by mouth twice a day.Review of P1's "Client Medication Report" dated for the certification period of 04/17/2025 to 07/15/2025 and provided by the agency, revealed Metoprolol Succinate ER (extended release) 25 mg one tablet by mouth twice a day.During an interview on 07/10/2025 at 1:30 PM, Registered Nurse (RN)1 RN1 stated, "I was not aware the Metoprolol had been changed. I will have to call the doctor about this." RN1revealed the medication report was reviewed at P1's group home with staff once a month. The Director of Nursing was not available for interview.During an interview on 07/11/2025 at 8:15 PM, the Administrator stated, "I expect the nurses to check our medication profile with the group home's medication list to make sure they are accurate."Review of the agency's policy titled, "Medication List and Monitoring," dated 09/01/2024, revealed, “…The Hospice registered nurse (RN)…creates and maintains a current medication/drug profile and reviews all patient medications both prescription and non-prescriptions, on an ongoing basis…"

Based on record review, interview, and agency policy review, the hospice agency failed to ensure that the required individuals (physician, registered nurse (RN), social worker, and/or chaplain) had documented signatures to indicate they attended the Interdisciplinary Group (IDG) meetings for four of 10 patients (Patient (P)1, P2, P8, and P9) out of a total sample of 14. This failure had the potential for the staff not to have knowledge of the patient's plan of care.Findings include: --- Review of the agency's policy titled, "Interdisciplinary Group (IDG/IDT)/Core Services," dated 09/01/2024, indicated, "…The IDG/IDT must include, but is not limited to individuals who are qualified in the following professional roles. They will include at least: A.    One physician who is a Doctor of Medicine or Osteopathy (may be [sic] a contract employee);B.    One registered nurse;C.    A social worker or mental health counselor or marriage and family therapist;D.    A pastor or counselor (which includes bereavement, dietary and/or spiritual counseling services) …"1. Review of P1's agency provided "Patient Information Report" revealed P1 was admitted to hospice services on 04/17/2025 with the terminal illness of senile degeneration of the brain.Review of P1's "IDT Meeting Minutes," dated 04/29/2025, indicated no evidence that the social worker or chaplain attended the meeting due to no signature on the sign in sheet.2. Review of P2's agency provided "Patient Information Report" revealed P2 was admitted to hospice services on 03/04/2025 with the terminal illness of senile degeneration of the brain.Review of P2's "IDT Meeting Minutes," dated 03/17/2025, indicated no evidence that the physician attended the meeting due to no signature on the sign in sheet.3. Review of P8's agency provided "Patient Information Report" revealed P8 was admitted to hospice services on 1/17/2025 with the terminal illness of chronic obstructive pulmonary disease.Review of P8's "IDT Meeting Minutes," dated 03/17/2025, indicated no evidence that the physician attended the meeting due to no signature on the sign in sheet.4. Review of P9's agency provided "Patient Information Report" revealed P9 was admitted to hospice services on 03/13/2025 with the terminal illness of malignant neoplasm of the colon.Review of P9's "IDT Meeting Minutes," dated 04/15/2025, indicated no evidence that the social worker attended the meeting due to no signature on the sign in sheet.During an interview on 07/11/2025 at 3:00 PM, the Medical Director stated, "If I attend in person, I will sign the sheet for the meeting. If I attend by Zoom, then someone at the office will have to sign the sheet for me since I am not there in person."During an interview on 07/11/2025 at 8:15 PM, the Administrator stated, "I do know the social worker was unable to attend a couple of the IDG meetings because the social worker is in the reserves. I don't remember about the medical director not attending."

Based on record review, interview and policy review, the agency failed to develop an individualized plan of care for 10 of 10 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, and P10) whose records were reviewed for plan of cares out of a total sample of 14. This failure had the potential for these patients not to receive the individualized care they needed.Findings include: --- 1. Review of P1's "Patient Information Report," provided by the agency, revealed P1 was admitted to hospice services on 04/17/2025 with the terminal illness of senile degeneration of the brain.Review of P1's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the electronic medical record (EMR) and dated for the certification period of 04/17/2025 to 07/15/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ." 2. Review of P2's "Patient Information Report," provided by the agency, revealed P2 was admitted to hospice services on 03/04/2025 with terminal illness of senile degeneration of the brain.Review of P2's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 03/04/2025 to 06/01/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."3. Review of P3's "Patient Information Report," provided by the agency, revealed P3 was admitted to hospice services on 03/04/2025 with the terminal illness of Parkinson's Disease.Review of P3's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 03/04/2025 to 05/02/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."4. Review of P4's "Patient Information Report," provided by the agency, revealed P4 was admitted to hospice services on 06/24/2024 with the terminal illness of senile degeneration of the brain.Review of P4's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 06/24/2024 to 09/21/2024, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."5. Review of P5's "Patient Information Report," provided by the agency, revealed P5 was admitted to hospice services on 08/12/2024 with the terminal illness of chronic obstructive pulmonary disease.Review of P5's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 08/12/2024 to 11/09/2024, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."6. Review of P6's "Patient Information Report," provided by the agency, revealed P6 was admitted to hospice services on 06/03/2025 with the terminal illness of malignant neoplasm of supraglottis and bronchus of the lung.Review of P6's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 06/03/2025 to 08/31/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."7. Review of P7's "Patient Information Report," provided by the agency, revealed P7 was admitted to hospice services on 03/01/2024 with the terminal illness of senile degeneration of the brain.Review of P7's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 03/01/2024 to 04/29/2024, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ." 8. Review of P8's "Patient Information Report," provided by the agency, revealed P8 was admitted to hospice services on 01/17/2025 with the terminal illness of chronic obstructive pulmonary disease.Review of P8's "Hospice Certification and Plan of Care," located under the 'Patient Chart" tab in the EMR and dated for the certification period of 01/17/2025 to 04/16/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."9. Review of P9's "Patient Information Report," provided by the agency, revealed P9 was admitted to hospice services on 03/13/2025 with the terminal illness of malignant neoplasm of colon.Review of P9's "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 03/1320/25 to 06/10/2025, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."10. Review of P10's "Patient Information Report," provide by the agency, revealed P10 was admitted to hospice services on 05/19/2024 with the terminal illness of Parkinson's Disease.Review of P10"s "Hospice Certification and Plan of Care," located under the "Patient Chart" tab in the EMR and dated for the certification period of 05/19/2024 to 08/16/2024, revealed, "Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional, and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Chaplain to evaluate patient/family/caregiver and develop a plan of care . . ."The Director of Nursing was unavailable for interview.During an interview on 07/11/2025 at 8:30 PM, the Administrator stated, "The doctor has to sign these orders, so the visits have not been made yet to know the plan of care for each patient."Review of the agency's policy titled, "Interdisciplinary Group (IDG/IDT)/Core Services," dated 09/01/24, revealed, ". . . The Hospice will designate an interdisciplinary group(s) that in consultation with the patient's attending physician, will prepare a written plan of care for each patient. The plan of care will specify the care and services to meet the patient and family specific needs . . . as such needs relate to the terminal illness and related condition . . ."

Based on interview, document review, and policy review, the hospice agency failed to have volunteer hours that equaled five percent of total patient hours. This had the potential to cause 16 out of 16 active patients to have unmet needs.Findings include: --- Review of the hospice agency's document titled, "Hospice Volunteer Requirement Report," revealed the agency's monthly volunteer hour percentages were:July 2024 – 0%August 2024 – 0%September 2024 – 0%October 2024 – 1.74%November 2024 – 1.30%December 2024 – 3.09%January 2025 – 0%February 2025 – 0%March 2025 – 0%April 2025 – 0%May 2025 – 3.47%June 2025 – 2.40%July 2025 – 2.42%This was an average volunteer hour percentage of 1.11% for July 2024 through July 2025.During an interview on 07/11/2025 at 7:00 PM, the Administrator revealed the agency had problems with getting volunteers once trained to give the agency the hours when the volunteers were available. The agency had increased efforts to recruit in new avenues but so far it had not helped.The Volunteer Coordinator was unavailable for interview.Review of the hospice agency's policy titled, "Volunteers" dated 09/01/24 revealed, ". . . Volunteers will provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid Hospice employees and contract staff . . ."

Upon observation, there was not evidence that the Hospice's Emergency Preparedness Plan included: Strategies for addressing those emergency events which were identified via their Hazard Vulnerability Risk Assessment, as the most likely to occur.

Upon patient record review, 1 of 6 (Patient #4) did not contain evidence that the Hospice Interdisciplinary Group, in consultation with the individual's Attending Physician (if any), had completed the Comprehensive Assessment no later than 5 calendar days after the Election of Hospice care. Patient #4 was admitted on 02/01/2022. The SW assessment was not conducted until 02/17/22.

Upon patient record review, 1 of 6 (Patient #4) did not contain a current/comprehensive Medication Profile. The most current POC dated 03/17/22 listed, "Oxygen 2 lpm p.r.n." Whereas the Medication Profile listed, "Oxygen 2-4 lpm p.r.n."

Upon patient record review, 1 of 6 (Patient #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; specifically complete/comprehensive orders for medications and treatments. The POC dated 03/17/22 listed Oxygen, without clarifying whether such administration was continuous or p.r.n.

Upon patient record review, 2 of 6 (Patients #1 and 3) 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; specifically Equipment and Supply needs: Patient #1: The most current IDG POC 03/17/22 listed Shower Bench as a patient DME. During the Surveyor-attended home visit on 03/17/22 the patient stated she "needed a Shower Bench". The admitting RN 02/10/22 had documented, "Ordered Shower Bench". Patient #3: The most current IDG POC 03/17/22 did not list a walker. The Surveyor noted a wheeled walker during the 03/17/22 home visit.

Upon personnel record review, 1 of 1 applicable Aide (Personnel #8) did not contain evidence that an initial Aide Skills Competency Assessment had been conducted, according to CMS guidelines. Aide competency contained no documented evidence that the following had been evaluated during the provision of patient care: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination

Upon patient record review, 3 of 3 applicable (Patients #2, 4, and 5) did not contain evidence that the RN-prepared Aide POC assignments and duties were individualized, and contained all pertinent patient information: Patients #2, 4, and 5: All of these Aide Plans of Care assigned the Aide to obtain T, P, R, and BP. However, neither these POCs, nor the Aide visit report(s), included the RN-determined parameters for these vital signs, outside of which the Aide would need to report such abnormal results. Patient #4: The clinical record reflected that this patient had a D.N.R. order. This pertinent patient information was not included on the Aide POC.

Upon patient record review, 2 of 2 applicable (Patients #5 and 6) did not contain a completed DC Summary which included all CMS-required content. For both of these DC Summaries the following content was not included: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Upon client record review, for 6 of 6 (Patients #1, 2, 3, 4, 5, and 6) there was no documented evidence that the Hospice had provided, and discussed, their Hospice's written policies and procedures on the management and Disposal of Controlled Drugs.