Mountain Ridge Hospice, LLC

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness documentation revealed the hospice did not ensure to complete an annual all hazard vulnerability assessment. There was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date. DOCUMENT 1: The Emergency Preparedness Policy on Risk Assessment stated in part, “The Hospice does an annual all hazard vulnerability assessment, based on risk assessment.” During a joint review of the Emergency Preparedness documentation and interview on 08/01/2025, the Administrator agreed there was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date. Additionally, the Administrator stated, “I have not been able to locate a hazard vulnerability risk assessment at all.” A review of the Emergency Preparedness documentation revealed the hospice did not ensure to complete an annual all hazard vulnerability assessment. There was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the hospice did not ensure the plan of care included measurable outcomes for patient and family goals. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/15/2024. The plan of care was reviewed for 10/15/2024-08/01/2025. Pain was identified as a problem on 12/23/2024 with the goal, “manageable pain.” The patient’s manageable level of pain was not identified. Edema was identified as a problem on 12/02/2024 with the goal, “lasix, compression stockings.” A measurable goal for the patient and family was not identified. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/05/2024. The plan of care was reviewed for 04/05/2024-08/01/2025. Chronic pain was identified as a problem on 04/05/2024 with the goal, “to keep the patient as comfortable as possible with proper pain medications.” The Registered Nurse (RN) assessment on 04/04/2025 and 06/27/2025 documented 8/10 pain. The RN assessment on 06/06/2025 documented 9/10 pain, Fentanyl patch, Methadone, and Dilaudid for pain control. The patient’s comfortable level of pain was not identified. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/22/2024. The plan of care was reviewed for 04/22/2024-08/01/2025. Poor appetite was identified as a problem on 04/22/2024 with the goal, “optimize nutrition.” The patient’s optimal nutrition level was not identified. During a joint review of the record and interview on 08/01/2025, the Director of Nursing agreed there was no documented evidence that the plans of care identified patient goals with measurable outcomes.”

“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; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; Safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, the hospice did not ensure that the staff followed the hand hygiene policy. DOCUMENT 3: Agency policy, Hand Hygiene, stated in part, “Hand washing with liquid soap and a paper towel or freshly laundered cloth towel is required before and after all patient contact. It is required to perform hand hygiene before and after touching the patient’s skin and items in the patient’s vicinity.” HOME VISIT 2: During the home visit with the Registered Nurse (RN) [Personnel Record 8] on 07/31/2025, The RN donned gloves, removed the dirty wound dressing from the left shin, cleaned with NS and gauze, applied moistened collagen, covered with a foam dressing, and compression stockings. Using the same gloves, the RN proceeded to the next wound and removed the dirty soiled dressing from the right shin, cleaned with NS and gauze, removed the phone from her pocket and took a picture of the wound, applied moistened collagen, covered with a foam dressing, and compression stockings. With the same gloves, the RN reached into the bag and removed bleach wipes and began to clean the vital sign equipment. The RN did not wash her hands or change gloves between dirty and clean wound care to two sites. The RN removed her gloves at the end of the visit, packed away the used wound supplies and placed the unused wound supplies on the patient’s bathroom counter before exiting the patient’s room at the facility. The RN did not wash her hands after removing her gloves or before exiting the patient’s room in the Assisted Living Facility. During a review of the home visit findings with the Director of Nursing on 08/01/2025, the Director of Nursing agreed that the RN did not follow the Hand Hygiene policy.”

“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. In 2 of 2 (100%) clinical records reviewed in which the patient revoked or was discharged for no longer being terminally ill revealed the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/26/2024. The patient was discharged, leaving service area-hospitalized, on 10/27/2024. There was no documented evidence the discharge summary was provided to the attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/17/2025. The patient was discharged, revocation, on 05/19/2025. There was no documented evidence the discharge summary was provided to the attending physician. During a joint review of the record and interview on 08/01/2025, the Director of Nursing agreed there was no documented evidence the discharge summary was completed or sent to the attending physician. Additionally, the Director of Nursing stated, “We did not know where to document the discharge summary but now we do. We had been sending the records only if requested. We will be updating our process.””