Hospice in the Desert LLC

“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. 2 of 14 (14%) clinical records reviewed of patients who received hospice services for 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 2: The patient elected the hospice benefit on 05/06/2026. 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 02/14/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator/Director of Patient Care Services/Registered Nurse stated in an interview on 07/07/2026, while performing joint clinical record review, agreed the clinical records were missing an initial bereavement assessment during the 5-day comprehensive assessment window.”

“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. 6 of 14 (43%) clinical records reviewed revealed the agency did not ensure the plans of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments completed by the interdisciplinary group (IDG). CLINICAL RECORD 2: The initial nursing assessment, dated 05/06/2026, documented the patient had bladder and bowel incontinence; significant weight loss since February 2026 - 154 pounds to current 133 pounds; and agitated easily because of decreasing ability to be independent with care. The IDG POC, dated 05/06/2026, lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence, nutrition, and agitation. CLINICAL RECORD 3: The initial nursing assessment, dated 06/11/2025, documented the patient had bladder and bowel incontinence, a significant weight loss (more than 10% in last 6 months), and increased agitation. The IDG POC dated 06/11/2025 lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence, nutrition, and agitation. CLINICAL RECORD 9: The initial nursing assessment, dated 07/25/2025, documented the patient had bladder and bowel incontinence, a significant weight loss (more than 10% in last 6 months), and increased pain. The IDG POC dated 07/25/2025 lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence, nutrition, and pain. CLINICAL RECORD 10: The initial nursing assessment, dated 10/01/2025, documented the patient had bladder and bowel incontinence and was wheelchair/bedbound. The IDG POC dated 10/01/2025 lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence and skin integrity. CLINICAL RECORD 11: The initial nursing assessment, dated 03/08/2026, documented the patient had bladder and bowel incontinence, and wheelchair-to-bed living. The IDG POC dated 03/08/2026 lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence and skin integrity. CLINICAL RECORD 12: The initial nursing assessment, dated 04/16/2026, documented the patient had bladder and bowel incontinence. The IDG POC dated 04/16/2026 lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence. The Administrator/Director of Patient Care Services/Registered Nurse stated in an interview on 07/07/2026, while performing joint clinical record reviews, that she agreed the clinical records were missing goals and interventions for multiple problems that were identified on the initial nursing assessments.”

“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 document review, interview and observation. 2 of 3 (67%) observation home visits revealed the agency did not ensure the clinicians performed hand hygiene in accordance with agency policy. Agency policy titled “Hand Hygiene”, #7-009 (Dated: 05/2023), stated in relevant part, “Procedure: 3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients; C. After contact with a patient’s intact skin.” HOME VISIT 2: The observed home visit with the Social Worker (Personnel Record 2) was completed on 07/07/2026. The Social Worker did not utilize hand gel to clean hands throughout the visit. She was observed touching multiple surface areas and reaching in and out of her tote without utilizing hand gel to clean her hands. Upon leaving the home visit, the site visitor asked the Social Worker if she had hand gel, and she stated, “I have hand gel in the car. I usually carry it with me. I know I’m supposed to use it during the visit.” HOME VISIT 3: The observed home visit with the Spiritual Counselor (Personnel Record 3) was completed on 07/07/2026. The Spiritual Counselor did not utilize hand gel to clean hands throughout the visit. She was observed touching multiple surface areas and reaching in and out of her tote without utilizing hand gel to clean her hands. Upon leaving the home visit, the site visitor asked the Spiritual Counselor if she had hand gel, and she stated, “I usually do. I know I’m supposed to use it during the visit.” The Administrator/Director of Patient Care Services/Registered Nurse, in an interview on 07/07/2026, agreed that the clinicians should at least be utilizing hand gel to clean hands, as needed, during patient visits in accordance with agency policy.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the “Hospice Volunteer Requirement Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the 2024 Hospice Volunteer Requirement Report revealed the volunteer percentage of hours worked for Calendar Year 2024 was 4.16%, Calendar Year 2025 was 2.51%, and Calendar Year 2026 (to-date: Jan-Jun) was 1.38%. The Alternate Administrator/Alternate Director of Patient Care Services/Nurse Practitioner/Registered Nurse stated in an interview on 07/07/2026 that she agreed the agency has fallen short of at least 5% average for volunteer hours completed since 2024. The review of the “Hospice Volunteer Requirement Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that the hospice medical director, physician designee, or physician member of the IDG reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition. This standard was not met as evidenced by clinical record review and interview. 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure the Certificate of Terminal Illness (CTI) and the narrative included the same primary diagnosis. CLINICAL RECORD 2: The Initial CTI narrative dated 05/06/2026 lacked evidence of having the same primary diagnosis as listed on the CTI. The CTI listed the primary diagnosis as “E43 Unspecified severe protein-calorie malnutrition”, and the narrative statement stated, “... with a primary hospice diagnosis of cerebrovascular accident with residual right-sided deficits...” CLINICAL RECORD 4: The Initial CTI narrative dated 12/18/2025 lacked evidence of having the same primary diagnosis as listed on the CTI. The CTI listed the primary diagnosis as “E43 Unspecified severe protein-calorie malnutrition”, and the narrative statement stated, “... with a primary hospice diagnosis of symptomatic abdominal aortic aneurysm with progressive enlargement...” CLINICAL RECORD 5: The Initial CTI narrative dated 11/25/2025 lacked evidence of having the same primary diagnosis as listed on the CTI. The CTI listed the primary diagnosis as “J96.01 Acute respiratory failure with hypoxia”, and the narrative statement stated, “... with a primary hospice diagnosis of advanced cardiopulmonary disease...” CLINICAL RECORD 8: The Initial CTI narrative dated 05/06/2026 lacked evidence of having the same primary diagnosis as listed on the CTI. The CTI listed the primary diagnosis as “E43 Unspecified severe protein-calorie malnutrition”, and the narrative statement stated, “... with a primary hospice diagnosis of cerebrovascular accident with residual right-sided deficits...” CLINICAL RECORD 14: The Initial CTI narrative dated 06/28/2026 lacked evidence of having the same primary diagnosis as listed on the CTI. The CTI listed the primary diagnosis as “C18.9 Malignant neoplasm of colon, unspecified”, and the narrative statement stated, “... with a primary hospice diagnosis of Metastatic liver malignancy ...” The Administrator/Director of Patient Care Services (DPCS)/Registered Nurse (RN) and the Alternate Administrator/Alternate DPCS/Nurse Practitioner/RN stated in an interview on 07/07/2026, while performing joint clinical record review, that they both agreed that the primary diagnoses listed on the CTIs that included a diagnosis code did not match the primary diagnoses the physician documented in the CTI narratives.”

“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 and interview. 1 of 2 (50%) clinical records reviewed of patients who were discharged revealed the agency did not ensure a copy of the discharge summary had been forwarded to the patient’s attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/14/2025 and was discharged to get care from a hospice that had an inpatient unit (IPU) on 09/12/2025. The record lacked evidence that the agency forwarded the discharge summary to the patient’s attending physician. The Administrator/Director of Patient Care Services (DCPS)/Registered Nurse (RN) and the Alternate Administrator/Alternate DPCS/Nurse Practitioner/RN stated in an interview, while performing joint clinical record reviews, on 07/07/2026 that they agreed the clinical records for the patient who was discharged from hospice to go to another hospice with an IPU was missing evidence that the discharge summary was forwarded to the patient’s attending physician.”