Every finding on record at Prairie View Healthcare,Inc.

Based on record review and interview, the hospice failed to ensure supervisory aide visits were completed every 14 days for two (Patient #2 and 3) of 14 patients. --- Findings:Patient #2A review of the plan care dated 03/18/25 t0 05/16/25 showed a hospice aide frequency of one visit per week for one week and two visits per week for eight weeks.  A review of the clinical record showed the following:Hospice aide visits were completed on 04/14/25 and 04/17/25 for the week of 04/13/25 to 04/19/25.A supervisory aide visit was completed on 04/17/25 for the week of 04/13/25 to 04/19/25.Hospice aide visits were completed on 04/21/25 and 04/24/25 for the week of 04/20/25 to 04/26/25.Hospice aide visits were completed on 04/28/25 and 05/01/25 for the week of 04/27/25 to 05/03/25.Hospice aide visits were completed on 05/05/25 and 05/08/25 for the week of 05/04/25 to 05/10/25.A supervisory aide visit was completed on 05/08/25 (21 days after the last supervisory aide visit) for the week of 05/04/25 to 05/10/25.Patient #3A review of the plan care dated 03/24/25 t0 05/22/25 showed a hospice aide frequency of two visits per week for nine weeks.  A review of the clinical record showed the following:Hospice aide visits were completed on 04/14/25 and 04/16/25 for the week of 04/13/25 to 04/19/25.A supervisory aide visit was completed on 04/15/25 for the week of 04/13/25 to 04/19/25.Hospice aide visits were completed on 04/21/25 and 04/23/25 for the week of 04/20/25 to 04/26/25.Hospice aide visits were completed on 04/28/25 and 04/30/25 for the week of 04/27/25 to 05/03/25.Hospice aide visits were completed on 05/05/25 and 05/07/25 for the week of 05/04/25 to 05/10/25.A hospice aide visit was completed on 04/14/25 for the week of 05/11/25 to 05/17/25.A supervisory aide visit was completed on 05/14/25 (29 days after the last supervisory aide visit) for the week of 05/11/25 to 05/17/25.On 07/08/25 at 11:50 am., Staff B stated the supervisory aide visits for Patients #2 and 3 were not completed every 14 days.

Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for 2024. --- Findings:A review of volunteer records and hours showed the hospice volunteers provided services that equaled 2.21% of the total patient care hours of all paid hospice employees for 2024. On 07/08/25 at 12:20 pm, Staff A stated the hospice volunteer services did not provide 5% of the total patient care hours of all paid hospice employees for 2024.

Based on record review and interview, the hospice failed to ensure it provided the most recent plan of care to a skilled nursing facility for one (Patient #2) of 14 patients. --- Findings:Patient #2A review of the hospice clinical record for skilled nursing facility #1 showed no current hospice plan of care.On 07/08/25 at 9:05 am., skilled nursing facility staff #1 stated the hospice failed to provide them with the hospice plan of care.On 07/08/25 at 12:00 pm., Staff B stated the hospice was not aware the current plan of care for Patient #2 was not provided to the facility.

Based on record review and interview, the hospice failed to ensure: 1. Completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for four (Patient #1, 2, 3 and 10) of 14 patients; and 2. Completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for five (Patient #1, 2, 3, 10 and 11) of 14 patients. --- Patient #1 A review of the clinical record showed an election of the hospice benefit on 07/21/22 with no completion of the initial spiritual assessment from 07/21/22 to 10/06/22 (78 days after election of the hospice benefit) and no completion of the initial psychosocial assessment from 07/21/22 to 09/06/22 (38 says after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #2 A review of the clinical record showed an election of the hospice benefit on 07/13/22 with no completion of the initial spiritual assessment from 07/13/22 to 10/06/22 (86 days after the election of the hospice benefit) and no completion of the initial psychosocial assessment from 07/13/22 to 10/06/22 (86 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #3 A review of the clinical record showed an election of the hospice benefit on 08/19/22 with no completion of the initial spiritual assessment from 08/19/22 to 11/16/22 (47 days after the election of the hospice benefit) and no completion of the initial psychosocial assessment from 08/19/22 to 10/06/22 (47 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #10 A review of the clinical record showed an election of the hospice benefit on 07/13/22 with no completion of the initial spiritual assessment from 07/13/22 to 10/06/22 (86 days after the election of the hospice benefit) and no completion of the initial psychosocial assessment from 07/13/22 to 10/06/22 (86 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #11A review of the clinical record showed an election of the hospice benefit on 06/16/22 with no completion of the initial psychosocial assessment from 06/16/22 to 09/13/22 (90 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. On 10/06/22 at 2:40 pm, Staff B stated the initial spiritual assessments, the initial bereavement assessments and the initial psychosocial assessments were not completed within the first five days after the election of the hospice benefit for Patients #1, 2, 3, 10 and 11.

Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for five (Patients #1, 2, 3, 10 and 11) of 14 patients. --- Patient #1 A review of the Initial Assessment dated 07/21/22 showed no assessment of imminence of death. Patient #2 A review of the Initial Assessment dated 07/13/22 showed no assessment of imminence of death. Patient #3 A review of the Initial Assessment dated 08/19/22 showed no assessment of imminence of death. Patient #10 A review of the Initial Assessment dated 09/22/22 showed no assessment of imminence of death. Patient #11 A review of the Initial Assessment dated 06/16/22 On 10/06/22 at 2:25 am, Staff B stated imminence of death was not assessed on the comprehensive assessment for Patients #1, 2, 3, 10 and 11.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eleven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) of 14 patients reviewed. --- Patient #1A review of the plan of care dated 07/21/22 to 10/18/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2A review of the plan of care dated 07/13/22 to 10/10/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3A review of the plan of care dated 08/19/22 to 11/16/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4A review of the plan of care dated 08/03/22 to 10/01/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5A review of the plan of care dated 07/28/22 to 10/25/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6A plan of care dated 09/03/22 to 12/01/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7A review of the plan of care dated 06/30/22 to 09/27/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8A review of the plan of care dated 06/23/22 to 09/20/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9A plan of care dated 08/05/22 to 10/03/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10A plan of care dated 09/03/22 to 12/01/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11A plan of care dated 06/16/22 to 09/13/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 10/06/22 at 2:15 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect the presence of pressure ulcers for one (Patient #4) of 14 patients. --- Patient #4 A review of the clinical record showed a plan of care dated 08/03/22 to 10/01/22 and plan of care updates dated 08/19/22, 09/02/22, 09/16/22 and 09/30/22 showed a primary diagnosis of chronic obstructive pulmonary disease, no presence of pressure ulcers or the care and management of pressure ulcers and a skilled nurse frequency of one visit per week for one week and three visits per week for eight weeks. A review of the clinical record showed the following: A skilled nurse visit dated 08/30/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 08/31/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/01/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/02/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/05/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/07/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/08/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/12/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/14/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/16/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/19/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/21/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/23/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/26/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/28/22 showed the development of pressure ulcers to the right and left heels. A skilled nurse visit dated 09/30/22 showed the development of pressure ulcers to the right and left heels. On 10/06/22 at 2:50 pm, Staff B stated the plan of care should have been updated to reflect the presence and care and services provided for the development of pressure ulcers for Patient #4.