Every finding on record at Shining Light LLC

Upon patient record review, 1 of 14 (Patient #1) 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 1:The medical record includes RN documentation that a PRN visit was made on 10/30/24 due to patient complaint of pain at 8 of 10. An order to increase frequency of existing Morphine 20mg/1ml 0.25 ml (5mg) from every 6 hours to every 4 hours received from physician during visit. There is no documentation of a reassessment by RN to determine if the patient's pain was relieved.

Upon patient record review, 2 of 14 (Patient #9,#11) 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 9 and 11:The medical record includes documentation that patient has a history of aspiration pneumonia, is ordered an alternate diet of mechanical soft and is at risk for aspiration. There is no evidence of problems, goals and interventions to manage the risk of aspiration.

Upon patient record review, 2 of 14 (Patient #3,#6) 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 3:The plan of care includes an order entered on 12/15/24 for wound care of cleanse with normal saline, pat dry, apply triple antibiotic, cover with dry dressing to be completed. There is no evidence that the orders include location of wound and who is to perform care. The plan of care includes an order for wound care entered on 7/28/24 to clean right buttock with wound cleanser then cover with silver alginate dressing 3 times a week. There is no evidence of who to perform care. Patient 6: The plan of care includes an order entered on 12/09/24 for wound care of cleanse skin tear to left and right buttock with normal saline, pat dry, apply Coloplast wound cream and cover with dry dressing to be completed 3 times weekly. There is no evidence that the orders include who is to perform care.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2:The aide plan of care includes the assigned task of dressing patient. There is no evidence that the frequency for the task to be performed is assigned.

Upon observation, there was no evidence that the Emergency Preparedness Plan included: Strategies for addressing those emergency events, as identified by the risk assessment, that would affect the Hospice's ability to provide care in such natural disaster.

Upon patient record review, 1 of 5 (Patient #4) did not contain a current/comprehensive Medication Profile, and/or that a review had been 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 #4: The H & P received from the referral source, listed patient allergies as both Compazine and Naproxen. However, the Medication Profile listed the only allergy as Naproxen.

Upon patient record review, 2 of 5 (Patients #1 and 2) did not contain evidence that the IDG had ensured that the care/services were provided in accordance with the Plan of Care: Patient #1: A Physician order was obtained on 10/11/21 for a Podiatry consult. There was no documented evidence that the Hospice had followed up on this order. Patient #2: The POC ordered both Social Work and Spiritual care/services to be provided at at frequency of 1x per month. There was neither a SW nor Chaplain visit made in the month of December 2021.

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not contain evidence that the following CMS-required Skills Competency Assessment was evaluated while observing the Aide performing the services to a patient. An RN observed the Aide for competence at multiple skills on 05/24/21. However, the following required tasks were not evaluated/documented as competent. These sections of the Skills Competency tool had been left blank: • Observation, reporting and documentation of patient status and the care or service furnished • Maintenance of a clean, safe, and healthy environment • Recognizing emergencies and knowledge of emergency procedures and their application • Normal range of motion • Adequate nutrition and fluid intake • The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice

Upon patient record review, 3 of 5 (Patients #3, 4, and 5) did not contain an Aide Plan of Care which was assigned by an R.N. member of the Interdisciplinary Group, and which POC specified the Aide tasks to be provided: Patient #3: The RN visit note of 12/31/21, in preparation for the second 90-day certification period, noted that the patient was now fully bed-bound. As of 01/18/22, the Aide POC continued to assign a shower with chair, instead of a bed bath. The same Aide POC assigned the Aide to "obtain vitals every visit". The Hospice RN did not provide the Aide with acceptable/unacceptable parameters, for which the Aide would need to report to the Hospice R.N. Patient #4: The Aide POC dated 10/12/21 assigned the Aide to "obtain vitals every visit". The Hospice RN did not provide the Aide with acceptable/unacceptable parameters, for which the Aide would need to report to the Hospice R.N. Patient #5: The Aide POC dated 06/26/21 assigned the Aide to "obtain vitals every visit". The Hospice RN did not provide the Aide with acceptable/unacceptable parameters, for which the Aide would need to report to the Hospice R.N.

Upon personnel record review, 1 of 11 (Personnel #6) did not contain evidence that all Hospice employees, and contract employees, had received orientation on the Hospice Philosophy.

Upon personnel record review, 1 of 10 applicable (Personnel #6) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel, including Volunteers, initially during orientation. Personnel #6 was hired on 04/15/21. The Skills Competency Checklist tool in her MSW file remained blank.

Upon patient record review, 2 of 5 (Patients #1 and 2) did not contain a signed Election of Hospice Statement, which included all required content, as follows: The effective date of the Hospice Benefit election; which may be the first day of Hospice care or a later date, but may be no earlier than the date of the Election Statement.

Upon patient client record review, 1 of 5 (Patient # 3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #3: The admission consent form reflected that the patient had a designated DPOA for Healthcare. However, the space intended for the Hospice to record this representative's name had been left blank. The DPOA was not identified within the clinical record.

Upon patient record review, 1 of 1 applicable (Patient #5) did not contain evidence that the Discharge Summary included all CMS-required information, as follows: • 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 personnel record review, 1 of 7 applicable (Personnel #11) did not contain evidence of a Criminal Background Check having been obtained in accordance with State requirements. In the absence of State requirements (Nevada State requirements do not apply to Volunteers). Criminal Background Checks are to be 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 was hired 02/12/21. As of survey date, there was no CBC filed in his HR file.