Every finding on record at Sierra Hospice & Palliative Care of Nevada, 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. In 3 of 14 (21%) clinical records reviewed that received hospice services at least five (5) days revealed the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/10/2026. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed by the SC on 01/17/2026 (Day 7). CLINICAL RECORD 7: The patient elected the hospice benefit on 03/03/2025. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed on 01/17/2026 (Day 11). CLINICAL RECORD 11: The patient elected the hospice benefit on 10/02/2025. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed on 10/09/2025 (Day 7). The Administrator/Director of Patient Care Services (DPCS)/Nurse Practitioner (NP), Alternative DPCS/Registered Nurse Case Manager (RNCM), and Alternate Administrator/Master of Social Work/Bereavement Coordinator/Volunteer Coordinator stated in an interview on 06/3/2026 that the SC did not complete the initial Spiritual assessment within the required initial 5-day comprehensive assessment.

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. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed that received hospice services at least five (5) days revealed the agency did not ensure that an initial bereavement assessment was completed as part of the initial comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/28/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/04/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/19/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/25/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/10/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/29/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/03/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/24/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/17/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/31/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/02/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/04/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/18/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/28/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator/Director of Patient Care Services (DPCS)/Nurse Practitioner (NP), Alternative DPCS/Registered Nurse Case Manager (RNCM), and Alternate Administrator/Master of Social Work/Bereavement Coordinator/Volunteer Coordinator stated in an interview on 06/3/2026 that the clinical records were missing an initial bereavement assessment as required by regulation during the 5-day comprehensive assessment window. The Administrator/DPCS/NP stated, "The initial bereavement assessment has been added to all existing active patients and is now set-up to be assigned to the admission RN and will be completed as required." It was also stated that the Bereavement Coordinator / MSW had been doing an initial bereavement assessment of sorts on an excel spreadsheet just not officially in the record - the EMR had changed and so that’s why it got missed. The bereavement assessment was immediately added to the clinical records before the visit ended.

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. In 4 of 8 (50%) clinical records reviewed, the hospice did not ensure the initial spiritual assessment, as part of the initial comprehensive assessment, was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 3: The patient elected the hospice benefit on 7/27/2023, with a terminal diagnosis of atherosclerotic heart disease. The initial spiritual assessment was dated 8/16/2023. There was no documented evidence in the clinical record that an initial spiritual assessment was completed no later than five days after the election of hospice care or reason for the delay. Clinical Record 5: The patient elected the hospice benefit on 6/24/2023, with a terminal diagnosis of sarcoidosis of the lung. There was no documented evidence in the clinical record that an initial spiritual assessment was completed no later than five days after the election of hospice care or reason for the delay. Clinical Record 6: The patient elected the hospice benefit on 6/16/2023, with a terminal diagnosis of chronic respiratory failure. There was no documented evidence in the clinical record that an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 8: The patient elected the hospice benefit on 6/16/2023, with a terminal diagnosis of chronic diastolic heart failure. There was no documented evidence in the clinical record that an initial spiritual assessment was completed no later than five days after the election of hospice care. During interview and joint clinical record review dated 8/17/2023, the Clinical Director agreed there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care. The Clinical Director stated, “we have identified this problem and are working on it.”

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. In 4 of 8 (50%) clinical records reviewed, the hospice did not ensure the plan of care was individualized to include planned interventions and goals based on problems in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 7/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The comprehensive assessment completed by the Registered Nurse (RN) dated 7/29/2023, included documentation that the patient’s pain level was 4/10 pain [pain level 0-10 scale, 0 is no pain, 10 is worst pain]. The RN assessment dated 8/8/2023 documented the patient’s pain was assessed at 6/10. Review of the patient’s medication profile revealed the patient had the following pain medications prescribed, Naproxen 500mg twice daily for pain, Meloxicam 15mg daily for pain, Gabapentin 300mg three times daily for pain, and Butalbital-ASA-Caffeine 50-325-40mg daily for pain. The plan of care dated 7/29/2023 through 8/16/2023 did not include problems, goals, and interventions related to the patient’s pain. Clinical Record 3: The patient elected the hospice benefit on 7/27/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris and a past medical history of diabetes type 2. The comprehensive assessment completed by the RN dated 7/27/2023, included documentation that the patient’s pain level was 3/10 pain. The RN assessment dated 8/14/2023 documented the patient’s pain was assessed at 5/10. Review of the patient’s medication profile revealed the patient had Morphine Sulfate ER 15mg twice daily prescribed for pain. The patient also had Gabapentin 400mg three times daily for pain, Glimepiride 2mg with evening meal daily, and Glimepiride 4mg with breakfast daily prescribed for diabetic management. The plan of care dated 7/27/2023 through 8/16/2023 did not include problems, goals, and interventions for pain and diabetes. Clinical Record 5: The patient elected the hospice benefit on 6/24/2023, with a terminal diagnosis of sarcoidosis of lung. The comprehensive assessment completed by the RN dated 6/26/2023, included documentation that the patient’s pain level was 10/10 pain, and the patient had a boil on the right buttocks. The RN assessment dated 7/11/2023 documented the patient’s pain was assessed at 5/10 and the patient had a wound to the right buttocks. The RN assessment dated 8/15/2023 documented a wound on right gluteal being treated with wound care. Review of the patient’s medication profile revealed the patient had Acetaminophen 500mg four times daily prescribed for pain. The plan of care dated 6/24/2023 through 8/14/2023 did not include problems, goals, and interventions for the patient's right buttocks wound and pain. Clinical Record 6: The patient elected the hospice benefit on 6/16/2023, with a terminal diagnosis of chronic respiratory failure and a past medical history of diabetes type 2. Review of the patient’s medication profile revealed the patient was prescribed Insulin Lispro SQ [subcutaneous] 100 unit/ml to be administered per sliding scale: 141-180=1 unit, 181-220=2 units, 221-260=3 units, 261-300=4 units, 301-340=5 units, 341-380=6 units. The patient’s plan of care date 6/16/2023 through 7/31/2023 did not include problems, goals, and interventions for diabetes. During interview and joint clinical record review dated 8/17/2023, the Clinical Director agreed there was no documented evidence the plans of care were individualized to include planned interventions and goals based on the problems identified.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed of live discharges, the hospice did not ensure the discharge summary was sent to the attending physician. Agency policy Revocation of Hospice Benefit, Policy No. 1-024 stated in part, “A discharge summary will be sent to the attending physician.” Clinical Record 7: The patient elected the hospice benefit on 6/16/2023, with a terminal diagnosis of unspecified combined systolic and diastolic heart failure. The patient revoked the hospice benefit on 6/20/2023 to seek aggressive treatment. There was no documented evidence that a discharge summary was sent to the patient’s attending physician. Clinical Record 8: The patient elected the hospice benefit on 6/16/2023, with a terminal diagnosis of chronic diastolic heart failure. The patient revoked the hospice benefit on 6/23/2023 to seek aggressive treatment. There was no documented evidence that a discharge summary was sent to the patient’s attending physician. During interview and joint clinical record review dated 8/17/2023, the Clinical Director agreed there was no documented evidence that the discharge summary was sent to the attending physician.