Every finding on record at Presbyterian Hospice of Northern Nm

Based on record review, observation and interview, the agency failed to ensure that the patient’s drug profile was current for 1 (P[patient]10) out of 4 (P6, P10, P17, and P18) patients.  This deficient practice could lead to patients not having an accurate medication list and errors. --- The findings are:A. Record review of the agency’s policy titled, “Medication Management HH [home health] and Hospice” dated 07/31/2025 under “Procedure” it stated, “B. Hospice: A drug regimen review will be performed at the time of initial and comprehensive assessment. The drug regimen review will be completed by the interdisciplinary group in consultation with an individual with education and training in hospice and palliation drug management to ensure that drugs and biological meet each patient's needs.4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to:     A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting.                                                                                                                  B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications.                                                                        C. Using the medication profile as a communication tool for other clinicians involved in care.B. During an observation on 12/02/2025 at 9:25 am in P10’s home, the patient had one medication list in the home that included five (5) medications and the plan of care had a total of 16 medications.  The medications on the home list for the caregiver to follow did not reflect her current plan of care and current drug profile. C. Record review of P10’s plan of care that was printed by facility on 12/01/2025 prior to home visit. The plan of care medication list had 16 medications, and the home list had 5 medications.     C. During an interview on 12/02/2025 at 9:25 am with the caregiver of P10 confirmed the medication list was the only list that had been provided to them and was given on the start of care with the hospice on 06/09/2025. D. During an interview on 12/02/2025 at 9:35 am S(staff)6, clinical, it was explained that the medication list in the home should be updated.

Based on record review, the facility failed to have a policy in place regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government). This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. --- The findings are:A. Record review of the agency’s policy titled, “Medication Management HH [home health] and Hospice” dated 07/31/2025 revealed no evidence of content related to management and disposal of controlled drugs. B. Record request for policies related to management and disposal of medications resulted in the policy above being provided.

Based on record review and observation, the agency failed to provide the patient or caregivers with information regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government) for 1 (P[patient] 18) out of 4 (P6, P10, P17, and P18) patients observed. This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. --- The findings are:A. Record review of the agency’s undated document titled, “Hospice Admission Booklet” revealed no evidence of information regarding the management and disposal of controlled drugs.B. During an observation on 12/03/2025 at 2:57 pm in P18’s home there was no evidence of information regarding the management and disposal of controlled drugs.

Based on record review and interview, the agency failed to document that the patient or caregivers were provided information regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government) for 4 (P[patient]2, P3, P6, and P7) out of 19 (P1-P19) patient records reviewed. This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. --- The findings are:A. Record review of P2’s record for start of care date 10/07/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.B. Record review of P3’s record for start of care date 02/01/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.C. Record review of P6’s record for start of care date 05/19/2024 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.D. Record review of P7’s record for start of care date 11/21/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.E. During an interview on 12/04/2025 on 2:15 pm with S(staff) 6, non-clinical, it was confirmed that there was no documentation of information provided to patient or caregivers regarding the management and disposal of controlled drugs.

Based on record review and interview, the agency failed to obtain a background check for 1 (S[staff] 2) out of 4 (S1, S2, S7, and S8) staff files reviewed. This deficient practice could put patients at risk when staff enter their homes if the agency is not aware of the staff’s background. --- The findings are:A. Record review of S2’s, clinical, employee file for hire date 02/06/2023 revealed that there was no background check on file.B. During an interview on 12/04/2025 at 1:15 pm with S6, non-clinical, it was confirmed that there was no background check on file for S2.

Based on record review and interview the facility failed to develop an emergency preparedness plan that includes strategies for addressing emergency events identified by the risk assessment. This deficient practice can delay the ability to offer continuity of patient care by not being prepared in case of an emergent situation and can lead to inappropriate treatment to all patients. --- The findings are: A. Record review of facilities policy titled; ";Emergency Operations Plan Hospice" effective date 03/15/2022, states under ";Planning Process -Before an Emergency: 2. Staff will work with regional or county emergency management planning agencies, where available in: A. Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis. B. Define organizations role in the community-wide emergency management program and all the organizations surge capacity. C. Develop and ";all-hazards" command structure within that links with the community command structure. 3. Specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities will be developed for each priority emergency". B. During interview with Staff (S)1, Administrator on 02/22/2023 at 11:50 am, when asked to provide communication plan, none could be provided. When asked to provide documentation showing strategies for each emergency event identified by the risk assessment and all-hazards approach, S1 could not provide. When asked to explain the procedure if an emergency was declared, S1 was able to explain. When asked where that procedure was written down, S1 answered, ";its not."

Based on record review and interview the agency failed to meet the Condition of Participation (CoP) for Initial & Comprehensive Assessment of Patient by failing to comply with the requirements as evidenced by the following: --- A. The agency failed to complete the IDG (Interdisciplinary Group) Comprehensive Assessment no later than 5 calendar days after the election of Hospice care Refer to L0523.

Based on record review and interview the agency failed to complete the IDG (interdisciplinary group) Comprehensive Assessment no later than 5 calendar days after the election of Hospice Care for 11 (P1, P2, P5, P8, P12, P14, P15, P16, P17, P18, P19) of 19 (P 1-19) patients reviewed. This failed practice could lead to failure to identify and fulfill patient/familys physical, psychosocial, emotional and spiritual needs at the start of care. --- The findings are: P1: A. Record review of P1 Consent for Election of Medicare Hospice Benefit signed by P1's Responsible Person on 08/10/2022. B. Record review of P1 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 08/10/2022 shows no notes from a social worker or a pastoral or other counselor within 5 days of election of Hospice Care. C. Record review of P1 Interdisciplinary Group Assessment titled "Hospice Plan of Care IDT Update" dated 08/10/2022 shows it was updated on 02/23/2023. P2: D. Record review of P2 Consent for Election of Medicare Hospice Benefit signed by P2's Responsible Person on 11/30/2022. E. Record review of P2 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 11/30/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. P5: F. Record review of P5 Consent for Election of Medicare Hospice Benefit signed by P5's Responsible Person on 2/17/2023. G. Record review of P5 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 02/17/2023 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. P8: H. Record review of P8 Consent for Election of Medicare Hospice Benefit signed by P8's Responsible Person on 02/14/2023. I. Record review of P8 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 02/14/2023 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. J. Record review of P8 Interdisciplinary Group Assessment titled "Hospice Plan of Care" dated 02/14/2023 shows it was updated on 02/23/2023. P12: K. Record review of P12 Consent for Election of Medicare Hospice Benefit signed by P12's Responsible Person on 12/05/2022. L. Record review of P12 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care Update dated 12/05/2022 shows no notes or contributions from a social worker within 5 days of election of hospice care. M. Record review of P12 Interdisciplinary Group Assessment titled "Hospice Plan of Care" dated 01/16/2023 shows it was updated on 02/23/2023. P14: N. Record review of P14 Consent for Election of Medicare Hospice Benefit signed by P14's Responsible Person on 10/30/2022. O. Record review of P14 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 10/30/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. P. Record review of P14 Interdisciplinary Group Assessment titled "Hospice Plan of Care IDT Update" dated 10/30/2022 shows it was updated on 02/23/2023. P15: Q. Record review of P15 Consent for Election of Medicare Hospice Benefit signed by P15's Responsible Person on 04/29/2022. R. Record review of P15 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 04/29/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. S. Record review of P15 Interdisciplinary Group Assessment titled "Hospice Plan of Care Update" dated 04/30/2022 shows it was updated on 02/23/2023. P16: T. Record review of P16 Consent for Election of Medicare Hospice Benefit signed by P16 on 11/08/2022. U. Record review of P16 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 11/08/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. P17: V. Record review of P17 Consent for Election of Medicare Hospice Benefit signed by P17's Responsible Person on 03/31/2022. W. Record review of P17 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 03/31/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. X. Record review of P17 Interdisciplinary Group Assessment titled "Plan of Care 1 Update A Action Required" dated 03/31/2022 shows it was updated on 02/23/2023. P18: Y. Record review of P18 Consent for Election of Medicare Hospice Benefit signed by P18 on 01/03/2023. Z. Record review of P18 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 01/03/203 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. AA. Record review of P18 Interdisciplinary Group Assessment titled Hospice Plan of Care Action Required dated 01/03/2023 shows it was updated on 02/23/2023. P19: BB. Record review of P19 Consent for Election of Medicare Hospice Benefit signed by P19 on 06/13/2022. CC. Record review of P19 Interdisciplinary Group Comprehensive Assessment titled Hospice Plan of Care dated 06/13/2022 shows no notes or contributions from a social worker or a pastoral or other counselor within 5 days of election of hospice care. DD. Record review of P19 Interdisciplinary Group Assessment titled Hospice Plan of Care Draft dated 09/10/2022 shows it was updated on 02/23/2023. EE. During an interview on 02/23/2023 at 1:15 pm with S(staff)1, Director, when asked why the social worker and chaplain notes were not included in the IDG Comprehensive Assessment, stated "I dont know why the IDG didnt populate the note that they wrote, It didnt pull it"

Based on record review the agency failed to obtain a written Physician's discharge order from the Hospice Medical Director in accordance with §418.26 and forward a discharge summary to the patient's attending Physician for 1 (P(patient)16) of 19 (1-19) patients reviewed. This failed practice could lead to a lack of coordination of care amongst the medical director and other Hospice staff and a lack of continuity of care after discharge. --- The findings are: Discharge Order: A. Record review of Registered Nurse home care visit notes for P16 dated 2/5/2023 states under "Discharge Information: D/C [discharge] date 2/5/2023, Discharge Disposition Discharged to Home of Self Care, Discharge Reason Patient no longer terminally ill." B. Record review of Electronic Medical Record for P16 shows no written physician's discharge order for 2/5/2023. C. When requested S (Staff) 2, RN Manager, to provide a Discharge Summary for P16, surveyor was provided with the following documents: Registered Nurse home care visit notes for 12/06/2022, 12/16/2022, 12/22/2022, 12/302022, 1/6/2023, 1/19/2023, 1/23/2023, 2/3/2023 and 2/5/2023. Hospice Plan of Care IDT update dated 1/20/2023 with physician's signature on 2/23/2023 at 1524 (3:34pm). There is no documentation of the written physician's discharge order. Discharge Summary: D. See Tag L684, no discharge summary exists for P16.

Based on record review and interview the agency failed to provide a discharge summary for 1 (P(patient)16) of 19 (1-19) patients reviewed. This failed practice could lead to a lack of continuity of care after discharge. --- The findings are: A. Record review of discharged patient list printed on 2/20/23 at 2:38 pm shows P16 with a discharge date of 2/5/2023 reason for discharge is "patient no longer terminally ill". B. Record review of P16 medical record revealed no proof of a discharge summary. C. When requested S(staff)2, RN (Registered Nurse) Manager, to provide a Discharge Summary for P16, surveyor was provided with the following documents: Registered nurse home care visit notes for 12/06/2022, 12/16/2022, 12/22/2022, 12/302022, 1/6/2023, 1/19/2023, 1/23/2023, 2/3/2023 and 2/5/2023. Hospice Plan of Care IDT update dated 1/20/2023 with physician's signature on 2/23/2023 at 1524 (3:34pm). There is no one document that contains a summary of the patent's stay including treatments, symptoms and pain management; current plan of care; and physician orders.