Every finding on record at Stellar Hospice Salt Lake LLC

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the aide provided services as included in the plan of care. CLINICAL RECORD 11: The aide plan of care, dated 07/14/2025, included visit frequencies of 3 times per week, and the following tasks to be completed each visit: hair care, skin care, and oral care. The hospice aide visit on 08/18/2025 did not document the assigned tasks of hair care, skin care, or oral care were completed. The record lacked a reason why the task was not completed. CLINICAL RECORD 12: The aide plan of care, dated 05/19/2025, included visit frequencies of 5 times per week, and the following task to be completed each visit: obtain weight. The hospice aide visit notes for 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 did not document assigned task of weight every visit was completed. The record lacked a reason why the task was not completed. CLINICAL RECORD 14: The aide plan of care, dated 08/01/2025, included visit frequencies of 3 times per week, and the following task to be completed each visit: hair care, skin care, foot care, oral care, elimination and home management. The hospice aide visit note dated 08/20/2025 did not document that the assigned tasks of hair care, skin care, foot care, oral care, elimination or home management were completed. The record lacked a reason why the task was not completed. On 08/27/2025, the Director of Nursing, acknowledged the aides did not follow the aide plan of care and although the electronic medical record allows documentation of the reason for not performing the task, she agreed no reasons was documented.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. CLINICAL RECORD 11: The aide plan of care, dated 07/14/2025, included visit frequencies of 3 times per week, and the following tasks to be completed each visit: hair care, skin care, and oral care. The hospice aide visit on 08/18/2025 did not document the assigned tasks of hair care, skin care, or oral care were completed. The record lacked documentation that the registered nurse (RN) was notified the plan of care tasks were not completed. CLINICAL RECORD 12: The aide plan of care, dated 05/19/2025, included visit frequencies of 5 times per week, and the following task to be completed each visit: obtain weight. The hospice aide visit notes for 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 did not document assigned task of weight every visit was completed. The record lacked documentation that the RN was notified the plan of care tasks were not completed. CLINICAL RECORD 14: The aide plan of care, dated 08/01/2025, included visit frequencies of 3 times per week, and the following task to be completed each visit: hair care, skin care, foot care, oral care, elimination and home management. The hospice aide visit note dated 08/20/2025 did not document that the assigned tasks of hair care, skin care, foot care, oral care, elimination or home management were completed. The record lacked documentation that the RN was notified the plan of care tasks were not completed. On 08/27/2025, the Director of Nursing, confirmed the records did not include documentation that the aides notified a RN when the plan of care was not followed.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services. This standard was not met as evidenced by document review, interview, and personnel record review. In 3 of 9 (33%) personnel record reviewed for individuals who are providing care, the agency did not ensure the staff were assessed for skills and competencies prior to caring of patients, in accordance with agency policy. Agency Policy 3.8, Competency Assessment (no date) stated in part, "As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing unsupervised care." Additionally, "competency evaluations are carried out by professional that have appropriate supervisory experience in the area of expertise of the person being evaluated (i.e., an Medical Social Worker (MSW) will perform competency exam on an MSW)." PERSONNEL RECORD 1: The Registered Nurse (RN) was hired on 12/30/2024. The document titled, "Competency Skills Checklist Registered Nurse" lacked a date completed and each individual skill evaluated lack preceptor's initials and dates. The RN completed orientation and was assigned care of patients without documented evidence of when the competency was completed. PERSONNEL RECORD 3: The Medical Social Worker (MSW) was hired on 09/23/2024. The document titled, "Competency Skills Checklist for Medical Social Worker" was completed by the Director of Nursing-Registered Nurse. As per agency policy, the evaluation must be conducted by an MSW. PERSONNEL RECORD 8: The Bereavement Coordinator was hired on 03/03/2025. The document titled, "Competency Skills Checklist for Bereavement Coordinator" was not completed. During an interview on 08/26/2025 with the Director of Nursing confirmed the competency skills checklist for Personnel Record 1 was incomplete and could not verify completion prior to assignment of patient care, Personnel Record 3 was completed by the Director of Nursing, and she stated she was unaware of the policy and procedure verbiage related to who could perform the evaluation, Personnel Record 8 she stated that no competency evaluation could be located in the personnel record.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including interventions to manage pain and symptoms, measureable outcomes anticipated from implementing and coordinating the plan of care and drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 2 of 6 (33%) clinical records reviewed revealed the hospice did not ensure plans of care included all services necessary for the palliation and management of the terminal illness, including interventions to manage symptoms. Record #68969: Start of Care (SOC) 3/21/2022. Diagnosis Parkinson’s disease, Comorbidities Insomnia. Plan of Care (POC) reviewed by IDG on 3/23/2022. Medication profile revealed patient taking Trazodone 50mg at hour of sleep for insomnia. The POC did not address the insomnia as a problem or include interventions with measurable outcomes anticipated from implementing and coordinating the plan of care and drugs and treatment necessary to meet the needs of the patient. Record #91968: SOC 12/13/2021. Diagnosis other transient cerebral ischemic attacks and related syndromes. Review of the comprehensive assessment completed on 3/14/2022 revealed “his son states that they believe he had a grand mal seizure last Thursday. Family is refusing medication at this time for seizures.” POC reviewed by IDG on 3/23/2022. The POC did not address the seizures or transient cerebral ischemic attacks as a problem or include interventions with measurable outcomes anticipated from implementing and coordinating the plan of care. The Administrator was interviewed on 4/28/2022. He agreed with the finding that the problems identified were not included in the POC with interventions to manage the symptoms.

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. This standard was not met as evidenced by observation, interview, and document review. 1 of 3 (33%) home visits revealed the hospice did not ensure the adherence to agency infection prevention and control policies and procedures for hand hygiene. During observation of Patient #56997 on 4/27/2022 at 10:30am, RN #16334 washed her hands, removed supplies from the nursing bag and completed the vital signs. The nurse was observed cleaning the blood pressure cuff and stethoscope and reached into the nursing bag to return the equipment without sanitizing her hands. Agency policy, “Hand Hygiene Policy and Compliance Program”, revised June 2019, stated in part, “Indications for hand hygiene are after direct patient care and before re-entering nursing bag.” The Director of Nursing was interviewed on 4/27/2022. She agreed with the finding that the staff did not follow agency policy and procedures for handwashing.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records of new admits revealed that the hospice election statement was not completed accurately. Record #56997: The patient elected hospice on 3/21/2022. The Notification of Covered/Non-covered items was not filled out with information on covered/non-covered items but was signed by the patient. Record #68969: The patient elected hospice on 3/21/2022. The Notification of Covered/Non-covered items was not filled out with information on covered/non-covered items but was signed by the patient. The Director of Nursing was interviewed on 4/27/2022. She agreed with the finding that the staff did not complete the Notification of Covered/Non-covered form accurately.

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. 1 of 4 (25%) applicable clinical records reviewed revealed that the MSW did not complete an initial comprehensive assessment within five days. Record #17145 was reviewed and identified that the patient elected hospice on 11/24/2021. The MSW initial assessment was not completed until 12/6/2021. There was a note in the system which indicated that MSW was not aware of admission on 11/24/2021. Interview completed with the Director of Nurses on 1/11/2022 confirmed that the initial MSW assessment was late and there was no additional information to provide.

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. 1 of 5 (20%) clinical records reviewed indicated a concern with the initial bereavement assessment conducted. Record #17145 was reviewed and identified that the patient elected hospice on 11/24/2021. There was no documentation that a Bereavement Assessment was completed. Interview with the Director of Nurses and Bereavement Coordinator occurred on 11/11/2021 and 11/12/2021 to discuss timing of the initial bereavement assessment. They both agreed that the bereavement assessment was missing and had no additional information to provide.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) applicable clinical records reviewed revealed that volunteer services were not provided per plan of care. Record #27989 was reviewed and identified that the patient elected hospice on 11/30/2021, The initial RN Assessment on 11/30/2021 indicated that the family requested volunteer services. The clinical record contained no documentation of coordination from Volunteer Coordinator or communication back to the family. Record #17145 was reviewed and identified that the patient elected hospice on 11/24/2021. The initial RN Assessment on 11/24/2021 indicated that the family requested volunteer services. The clinical record contained no documentation of coordination from Volunteer Coordinator or communication back to the family. Interview with the Director of Nurses (DON) and Volunteer Coordinator (VC) on 1/11/2021 revealed that there was no communication to the Volunteer Coordinator about the request for volunteers. The DON and VC discussed plans for better coordination. There was no additional information to provide

It is required that a written agreement with another organization or individual to furnish hospice care or services includes: The scope of services to be provided; How Interdisciplinary Group (IDG) management oversight and coordination is provided; How communication with the IDG and hospice administration occurs; Care provided only upon authorization of the hospice; Care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice; Care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by contract review and interview. 1 of 6 (17%) of contracts reviewed revealed that the contract did not identify the name of the hospice. [NAME OF CONTRACTED PROVIDER] contract for PT/OT/ST indicated that the contracting entity was with [CORPORATE NAME-NOT SPECIFIC TO INTERMOUNTAIN HOME HEALTH INC]. In an interview with the Administrator on 1/11/2022 he indicated that he believed that since both companies were under the same umbrella that a new contract would not be needed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by record review and interview and identified the agency failed to ensure the clinical record contained an accurately completed hospice election statement (L673) and failed to ensure clinical records contained physician orders for care provided (L678).

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 4 of 5 (80%) clinical records reviewed revealed that the hospice election statement was not completed accurately. Record #66101 was reviewed and identified that the patient elected hospice on 11/5/2021. In review of the NOE/ (Notice of Election)/Consents was signed by granddaughter but the HPOA (Healthcare Power of Attorney) was identified as a different family member (son). The notice of election did not indicate why patient was not able to sign. Record #52799 was reviewed and identified that the patient elected hospice on 12/12/2021. The Notification of Covered/Non-covered items was not filled out with information on covered/non-covered items but was signed by the patient. Record #17145 was reviewed and identified that the patient elected hospice on 11/24/2021. The notice of election did not indicate why patient was not able to sign. The Notification of Covered/Non-covered was not filled out with information covered/non-covered items but was signed by the POA. Record #27989 was reviewed and identified that the patient elected hospice on 11/30/2021. The notice of election did not indicate why patient was not able to sign. The Notification of Covered/Non-covered was not filled out with information covered/non-covered items but was signed by the POA. The Director of Nursing was interviewed on 1/11/2022 and agreed that there were issues with the "Consent Process" and has developed a PIP to provide education to the team and to monitor the results. There was no additional information to provide

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. 3 of 5 (60%) clinical records reviewed revealed that there were missing physician orders. Record # 66101 was reviewed and revealed that patient elected hospice on 11/5/2021. In a nursing note dated 11/11/2021 it was noted that the patient required a suction machine, there was no order present in the clinical record. In a nursing noted dated 11/26/2021 it was noted that an ace bandage and ice were recommended for the left knee, there was no order present in the clinical record. Record #27989 clinical record was reviewed and revealed that patient elected hospice on 11/30/2021. The initial RN assessment on 11/30/2021 stated that the patient "has maceration on his Left coccyx along with two spots that are a stage one pressure ulcer. Hydrocolloid dressing was placed". There was no order present for wound care in the clinical record. Record #17145 clinical record was reviewed and revealed that patient elected hospice on 11/24/2021. In a nursing note dated 11/29/2021 in was stated that wound care was increased to three times a week to include Medihoney and Mepilex dressing and that Gabapentin was to be increased to 300mg TID (three times a day). There was no order present in the clinical record. In a nursing note on 12/9/2021 it stated that the hospice MD ordered Atropine for increased secretions and increased the Morphine and Ativan to 0.75ml every four hours PRN. There was no order present in the clinical record. The Director of Nrses was interviewed on 1/12/2022 and agreed that there were missing orders. There were issues related to the EMR and where orders were being sent, however, these orders were not present after the EMR issue was resolved. There was no additional information to provide.