Every finding on record at Pebble Creek of Las Vegas, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 4 of 11 (36%) clinical records reviewed revealed the hospice did not ensure the initial comprehensive assessment was completed within 5 days of the election of hospice care. Record #41439 was reviewed and identified the patient elected hospice care on 11/4/2021. The clinical record did not contain an initial psychosocial comprehensive assessment within 5 days. Record #61255 was reviewed and identified the patient elected hospice care on 12/14/2021. The clinical record did not contain an initial psychosocial comprehensive assessment within 5 days. Record #83177 was reviewed and identified the patient elected hospice care on 10/29/2021. The clinical record did not contain an initial psychosocial comprehensive assessment within 5 days. Record #37252 was reviewed and identified the patient elected hospice care on 7/30/2021. The clinical record did not contain an initial psychosocial comprehensive assessment within 5 days. The Director of Clinical Services was interviewed on 2/9/2022 and stated the initial assessments within the records identified were not completed within the required 5 days.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 4 of 11 (36%) clinical records reviewed revealed the hospice did not ensure the clinical records contained an initial bereavement assessment. Record #14907 was reviewed and identified the patient elected hospice care on 10/13/2020. The clinical record did not contain an initial bereavement assessment. Record #61255 was reviewed and identified the patient elected hospice care on 12/14/2021. The clinical record did not contain an initial bereavement assessment. Record #19270 was reviewed and identified the patient elected hospice care on 8/19/2021. The clinical record did not contain an initial bereavement assessment. Record #37252 was reviewed and identified the patient elected hospice care on 7/30/2021. The clinical record did not contain an initial bereavement assessment. The Administrator was interviewed on 2/9/2022 and stated there were no initial bereavement assessments present within the records identified.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure that the plan of care included patient and family goals, along with interventions, to manage symptoms. Record #15515 was reviewed and identified a comprehensive assessment was completed on 12/22/2021. The documentation revealed, “increased SOB on minimal exertion requiring O2 at 3L daily and continuously at night.” The plan of care dated 12/22/2021, which identified respiratory issues as a problem, did not include evidence of interventions or goals to address the shortness of breath. Record #29026 was reviewed and identified a comprehensive assessment was completed on 11/10/2021. The documentation revealed, “SOB upon exertion, pursed lip breathing at times, use of accessory muscles evident, wheezing, persistent cough.” The plan of care dated 11/10/2021, which identified respiratory issues as a problem, did not include evidence of interventions or goals to address the shortness of breath. Record #61255 was reviewed and identified a comprehensive assessment was completed on 12/14/2021. The documentation revealed, “severe pain to lower back, roxanol and lorazepam administered with good effect.” The plan of care dated 12/14/2021, which identified pain a a problem, did not include evidence of goals to address the pain. The Director of Clinical Services was interviewed on 2/9/2022 and stated, the plan of care within the records identified were not completed with the required goals and interventions.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and Safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by observation, interview, and document review. 1 of 3 (33%) home visits revealed a clinical staff member did not demonstrate adherence to the agency's infection prevention and control policies and procedures. Record #14907: During a home visit observation on 2/9/2022 at 8:10 am, the registered nurse (RN #54781) washed her hands, donned gloves and removed wound supplies from the nursing bag. The nurse began wound care and placed the drainage-soiled wound dressing on the barrier, removed one glove, and reached into the nursing bag to retrieve additional supplies without first sanitizing their hand. The RN then re-gloved without sanitizing her hands and continued the wound care. The nurse returned used bandage scissors to the nursing bag without sanitizing them first. and was observed removing her gloves and re-gloving without sanitizing her hands prior to taking the patient’s vital signs. The agency's policy, "Infection Prevention and Control, Hand Hygiene, Policy No. 9-009-1”, revised January 2022, stated hand decontamination should be performed: “... after contact with wound dressing... after contact with inanimate objects (including medical equipment) in the patient's vicinity... and after removing gloves.” Also, the agency's policy, "Infection Prevention and Control, Bag Technique, Policy No. 9-014-1”, stated, in part: “When the visit is completed, reusable equipment will be cleaned using antibacterial wipe and/or soap and water as appropriate, hand hygiene completed, and equipment and supplies will be returned to the bag. Hands will be decontaminated prior to re-entering the bag.” The Director of Clinical Services was interviewed on 2/9/2022 and stated, the nurse did not follow the agency's policies and procedures for hand hygiene.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties, the needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review and interview. 1 of 10 (10%) personnel records reviewed revealed there was no documented evidence that an initial orientation was provided. Record #17272: The personnel record for this MSW, who was hired on 1/13/2020, was reviewed and revealed there was no evidence that an orientation was provided upon hire. The Administrator was interviewed on 2/9/2022 and stated there was no documented orientation within the record identified.