Auburn Crest Hospice Treasure Valley, LLC

“Observed in Record Review. In 8 of 19 patient records reviewed, the initial bereavement assessment was not completed per organizational policy on the family and caregivers. In HOSRRHV #1 the bereavement assessment was done on one of the patient’s children, a daughter and a son who were also involved in the patient’s care were not assessed. In HOSRRHV #2 there was a son, daughter, and daughter in law involved in the patient’s care and only the son had a bereavement assessment completed. In HOSRRNHV #1 only one son was assessed, the other son and daughter in law were not. In HOSRRDC #1 the spouse was assessed but the son was not. In HOSRRBRV #2 there were 2 children involved in the patients care and only one was assessed. In HOSRRHV #3 there were 5 children involved in the patient’s care and only one daughter was assessed. In HOSRRNHV #6 the spouse was assessed but the daughter was not. In HOSRRNHV #8 there was a change in the POA and the new POA did not have a bereavement assessment completed. Per the organization’s Bereavement Policy it stated, the initial bereavement assessment will include the patient’s family and caregivers. This was reviewed and validated with the Compliance Officer.”

“Observed in Record Review. In 12 of 19 patient records reviewed, the organization failed to plan the patients care. The hospice surveyor observed that the chaplain goals were not measurable . They were the same care plan for the following patients, HOSRRHV #1, HOSRRNHV #1-#6, HOSRRNHV #7, HOSRRNHV #10, HOSRRDC #1, and HOSRRBRV #1- #3. The care plans stated, Patient and caregiver will achieve feelings of spiritual comfort. It was not clear what or how the patient’s were to achieve spiritual comfort. This was reviewed and validated with the Compliance Officer..”

“Observed in Record Review. In 12 of 19 patient records reviewed, the organization failed to plan the patient’s care with medications and treatments necessary to meet the patient’s needs. In HOSRRHV #1, HOSRRHV#2, HOSRRNHV #1, HOSRRBRV #1, HOSRRBRV #3, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #5, HOSRRNHV #7, and HOSRRNHV #10 the patient had orders for Acetaminophen 325 mg oral every 4 hours and prn for mild pain and Morphine Sulfate 20mg/ml sublingual every hour as needed for pain. In HOSRRNHV #2 the patient had orders for ibuprofen 200 mg twice daily for pain and Morphine Sulfate 20mg/ml sublingual every hour as needed for pain. It is not clear when the Morphine Sulfate should be used. In HOSRRNHV #8 the patient had orders for Acetaminophen 325 mg 2 tablets by mouth every 4 hours for pain, Acetaminophen Hydrocodone 325-5mg every 6 hours as needed for pain, and Morphine Sulfate 20 mg sublingual every 2 hours for pain. It is not clear when to take on over the other. In HOSRRNHV #1 the patient had a diagnosis of epileptic seizures. The RN care plan did not include a care plan on seizure precautions. In HOSRRBRV #2 the patient was assessed to be a fall risk but the care plan did not include a interventions related to fall risk.. This was reviewed and validated with the Compliance Officer.”

“Observed in Record Review. In 1 of 3 patient records reviewed, where bereavement services were provided, the surveyor observed in HOSRRBRV #3 that the bereavement risk assessment indicated that the bereaved was at a moderate risk, yet the only interventions planned was to send a standard series of mailings which were provided to all low risk patient, with no indication of other proposed interventions. The chaplain stated that he called the patient monthly but this intervention was not included in the Plan of Care. The organization’s Bereavement Policy stated that for Moderate to High risk patients additional services would be provided outside of the standard series of mailings to the family and or caregivers. This was reviewed with the Compliance Officer.”

“Observed in HR File Review. In 1 of 7 HR files reviewed, During survey there was no documented evidence of annual competence assessments. In HR #4 the MSW who was also the Bereavement Coordinator and Volunteer Coordinator did not have on going competencies for Bereavement Coordinator or Volunteer Coordinator for the last 3 years per agency policy. This was reviewed and validated by the Compliance Officer. Observed in Tracer Activities. In 1 of 15 HR files reviewed, staff were not deemed initially competent to perform their responsibilities. The hospice surveyor observed that the Medical Director at Twin Falls did not have an initial competency done until 10 months after hire. This was reviewed and validated with the Compliance Officer.”

“Observed in Patient Home. In 2 of 2 home visits conducted, where a nurse performed medication reconciliation, the surveyor observed that the medication list was discovered to be inaccurate. In HOSRRHV#1 the medication list had acetaminophen-caffeine 500mg-65mg oral tablet one every day for mild pain. This was ordered 23 days ago from survey and the medication technician at the assisted living said that she has never given this medication to the patient should take one of these medications or both for constipation. In HOSRRHV #3 the patient was on the following medications Latanoprost ophthalmic .005% emulsion take one drop to affected eye, no documentation as to which is the affected eye, duplicate medications for pain, Tramadol 50 mg take 1 tablet oral 2 times a da as needed for mild pain, Acetaminophen-hydrocodone 325-5 mg oral 1 tab every 6 hours for pain, and Acetaminophen 325 mg 2 tablet every 6 hours as needed for mild pain, it is not clear which medication should be used first, and Polyethylene glycol 17 grams orally one a day for constipation and Magnesium Citrate 1.745g/30 ml once a day as needed for constipation. Again no indication which medication to take first. This was reviewed and validated with the Compliance Officer.”

“Observed in Tracer Activities. In 4 of 15 HR files reviewed, primary source verification of licenses and certificate, required by law, were not validated at time of hire, through renewal or at time of expiration. Hospice surveyor observed that the Medical Director and Interim Director of Nurses did not have license renewal validation. The medical directors license renewal at Boise was done 3 months after the expiration date. The Interim Director of Nursing is missing renewal validation from 2023 and 2025. The HHA did not have license verification done prior to the expiration of her license. The verification was done 3 days after her license expired. The nurse in Twin Falls did not have her license verified at hire until one month after her start date. This was reviewed and validated with the Compliance Officer.”