Every finding on record at Valley Hospice of Nevada LLC

Upon patient record review, 7 of 14 (Patients #1,2,3,4,5,6,8) did not have evidence in the patient record that a review was 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 #1: Patient had Juven 7gm oral powder daily with no diluent. Corrected on Site. Patient #2: Methenamine Hippurate 1gm tablet listed as daily on hospice medication profile and twice daily on facility medication profile. Corrected on Site. Patients #3,4,5,6,8: The record indicated this patient was on Oxygen treatment. Oxygen was not included on the Medication Profile. Corrected on Site.

Upon patient record review, 2 of 14 (Patients #1,2) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Patient had Juven 7gm oral powder daily with no diluent on POC. Corrected on Site. Patient #2: Methenamine Hippurate 1gm tablet listed as daily on hospice POC. The order was for twice daily. Corrected on Site.

Upon patient record review, 5 of 14 (Patients #1,2,3,4,5) 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 equipment and supply needs. Patient #1: This patient had a shower chair, rollator and wheel chair. These were not included on the Plan of Care. Corrected on Site. Patient #2: This patient had a walker and wheel chair. These were not included on the Plan of Care. Corrected on Site. Patient #3: This patient had a hospital bed and wheel chair. These were not included on the Plan of Care. Corrected on Site. Patient #4: The record reflected that this patient had an oxygen concentrator and suction machine. These were not included on the Plan of Care. Corrected on Site. Patient #5: The record reflected that this patient had an oxygen concentrator and nebulizer machine. These were not included on the Plan of Care. Corrected on Site.

Upon observation, there was no evidence the hospice not following accepted standards of practice to prevent the transmission of infections. Agency has TST testing solution (Sanofi Pasteur Limited) in a locked box in a door shelf of a small refrigerator. They are doing temperature controls checks. However, there is a subway sandwich and bottled drink on a shelf inside the refrigerator.

Upon patient record review 2 of 14 (Patients #2, 4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care (POC) Patent #2: The POC listed Aide visit frequency of 2 X's per week beginning 1/8/25. For the first benefit week, there was only 1 visit on 1/10/25. Patient #4: The POC listed Aide visit frequency of 3 X's per week beginning 6/6/24. For the first benefit week, there was only 1 visit on 6/7/24.

Upon patient record review, 14 of 14 (Patients #1 through #14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1 through #14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. EOB Form updated to be used going forward-Corrected on Site.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: The receiving hospice requested medical records be faxed to them. This patient discharged on 12/26/24 and agency sent documents during survey on 1/16/25.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12: There is no evidence that the patient's plan of care was included in discharge summary documents.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records according to Nevada Revised Statutes (NRS) 449.176 through NRS 449.188. Personnel#10: The Medical Director did not have evidence of Criminal Background check in her file. Agency provided a correspondence email from Background Check Program at Bureau of Health Care Quality and Compliance that confirmed this provider has had previous Nevada's Automated Background Check System (NABS) background checks for other facilities, but not for Valley Hospice of Nevada. This provider did get fingerprints completed for processing with hospice agency on 1/16/25.

Upon client record review, 3 of 5 (Patient #1,2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 MSW order for frequency 1x every 4 weeks, visits completed on 11/12/21, 12/30/21, 1/28/22. SC order for frequency 1x every 4 weeks, visits completed 11/11/21, 12/4/21, 12/11/21, 12/17/21, 12/23/21, 1/15/22, 1/29/22. Patient #2, MSW order for frequency 1x every 4 week, Initial visit on 11/8/21 with patient declining further visits, no order to decrease visits. SC order frequency 1x every 4 weeks, visits completed on 11/6/21, 11/8/21, 11/15/21, 11/22/21, 11/29/21, 12/6/21, 12,14/21, 12/2021, 12/27/21, 1/6/22, 1/10/22, 1/31/22 without order for change in frequency. Patient #3, MSW order for frequency 1x every 4 weeks with Initial visit on 11/19/21 with patient declining further visits, no order to decrease visits.

Upon observation of the home visit, 1 of 3 applicable (Patient 1,2,3) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,2,3, during home visit, RN did not wash hands prior to donning gloves. RN went in and out of bag multiple times without washing hands with soap and water or utilization of hand sanitizer.