St Mary’s Hospice of Northern Nevada

“Based on record review, interviews, and policy review, the agency failed to ensure the initial spiritual assessment was completed within five calendar days after the start of hospice care for 3 of 13 active patients (Patients (P) 5, P6, and P12) whose records were reviewed for spiritual assessments; the agency failed to ensure the initial psychosocial assessment was completed within five calendar days after the start of hospice care for 2 of 13 active patients (P6 and P7) whose records were reviewed for psychosocial assessments. This deficient practice had the potential to cause the patients’ desired wishes to not be honored. Findings include: There was no documented evidence the agency completed the initial spiritual and/or psychosocial assessment within five calendar days after the start of hospice care for 4 of 13 active patients (P5, P6, P7 and P12) reviewed for initial assessments out of a total sample of 19. The agency had no documented check and balance system to ensure the spiritual and psychosocial assessments were completed on time. Refer to L523.”

“Based on record review, interview, and policy review, the agency failed to ensure initial spiritual and/or psychosocial assessments were completed within five days after election of hospice care for 4 of 19 sampled patients (Patient (P) 5, P6, P7, and P12). This deficient practice had the potential to cause the patients to have unmet care needs. Findings include: Review of the agency’s policy, “Psychosocial Assessment,” revised 02/01/2023, indicated “. . . Procedure: The SW (social worker) will complete a psychosocial assessment and plan of care for each patient no later than five days after the date of the hospice election . . .’’Review of the agency’s policy, “Spiritual Assessment,” revised 02/01/2023, indicated “. . . Procedure: The Chaplain or qualified spiritual counselor will complete a spiritual needs assessment and plan of care (for) patient and family no later than five days after the date of hospice election . . .’’1. P5’s “Patient Information Report” indicated the patient was admitted to hospice services on 01/09/2023 with a diagnosis of acute pancreatitis. A review of the patient’s entire electronic medical record (EMR) revealed no documented evidence of a spiritual needs assessment. During an interview on 01/29/2025 at 4:37 PM, the Interim Executive Director (ED) confirmed there was no spiritual assessment in P5’s EMR. The Interim ED confirmed the agency did not have a check and balance system to ensure the initial assessments were completed.2. P6’s “Patient Information Report” indicated the patient was admitted to hospice services on 04/09/2024 with a diagnosis of senile degeneration of the brain. A review of the patient’s entire EMR revealed no documented evidence of a spiritual needs assessment. The EMR included a psychosocial assessment completed by the social worker (SW) on 04/16/2024, seven days after the patient’s admission to hospice services. During an interview on 01/29/2025 at 5:30 PM, the Interim ED confirmed the SW’s assessment was completed outside of the initial five-day time frame and confirmed there was no spiritual needs assessment. The ED confirmed the expectation was for the assessments to be completed within the correct time frame. 3. P7’s “Patient Information Report” indicated the patient was admitted to hospice services on 07/23/2024 with a diagnosis of Parkinson’s disease. A review of the patient’s entire EMR revealed no documented evidence of a psychosocial assessment. During an interview on 01/29/2025 at 5:59 PM, the Interim ED confirmed there was no psychosocial assessment and indicated the SW was expected to talk with the team to ensure there was coverage to complete the assessment. 4. P12’s “Patient Information Report” indicated the patient was admitted to hospice services on 07/25/2024 with a diagnosis of Alzheimer’s disease. A review of the patient’s entire EMR revealed no documented evidence of a spiritual needs assessment. During an interview on 01/30/2025 at 3:44 PM, the Interim ED confirmed the spiritual needs assessment was not completed and should have been.”

“Based on record review, interviews, and policy review, the agency failed to ensure that 1of 19 patients (Patient (P) 19) had their medications reconciled to match the original physician orders. This deficient practice had the potential to affect the accuracy and effectiveness of medications ordered for the patient. Findings include: Review of the agency’s policy, “Monitoring Medications,” revised 11/01/2017, indicated, “. . . A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period . . . The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: A comprehensive medication review will be completed on admit and at every interdisciplinary group (IDG) meeting, in conjunction with all comprehensive assessments. Compare medication list to actual medications patient is taking . . . Review over the counter (OTC) medications, vitamins, herbs, and herbal products, and creams and topical ointments and medical marijuana (in states where legalized) to identify issues . . .”A review of P19’s “Patient Information Report” indicated the patient was admitted to hospice on 01/09/2025 with a diagnosis of congestive heart failure (CHF). P19’s “Medicine List,” dated 01/09/2025, indicated physician orders for ammonium lactate (lotion for dry skin) 12% lotion, apply thin layer to affected areas twice a day (BID) for dry skin; atorvastatin (for high cholesterol) 40 milligrams (mg) daily; bumetanide (to decrease edema) two mg BID; vitamin D3 (to increase calcium levels) 25 micrograms (mcg) daily; metolazone (to decrease edema) five mg every other day; oxygen 2.5 liters continuously via nasal cannula for hypoxemia (low oxygen levels); potassium chloride (potassium replacement) extended release 10 milliequivalents (mEq) daily; and sacubitril 24 mg-valsartan 26 mg (for heart failure) BID. Upon initial entry to the home for observation on 01/28/2025 at 12:15 PM with Registered Nurse (RN1), P19 was observed sitting in a chair watching television, not connected to their oxygen. P19 indicated they only used the oxygen while in the bedroom because the dogs got tripped up in the cord. RN1 asked if P19 was having any shortness of breath (SOB). The patient denied having SOB and said if it occurred, they would use their inhaler, which worked. Around 1:30 PM, as RN1 completed a medication reconciliation with P19 and their power of attorney (POA) the POA stated P19 did not apply the ammonium lactate 12% lotion BID, and did not take the medications bumetanide two mg BID, vitamin D3 25 mcg daily, metolazone five mg every other day, and potassium chloride extended release 10 mEq daily. As the reconciliation continued, RN1 noted that P19’s atorvastatin 40 mg bottle had instructions to take one 20 mg tablet daily for hyperlipidemia, instead of the physician orders which indicated one 40 mg tablet daily. RN1 confirmed the bottle’s instructions and that no additional bottles were available. RN1 also noticed the sacubitril 24 mg-valsartan 26 mg bottle instructed P19 to take one tablet daily instead of the physician-ordered one tablet twice a day. P19’s physician, who had arrived for a 2:00 PM visit, observed the bottle and confirmed the instructions should be for one tablet twice a day as originally ordered, with which RN1 agreed. During an interview on 01/29/2025 at 2:38 PM, the Quality Assurance (QA) Coordinator indicated the nurses were responsible for checking medications whether the patient was in the home or in a facility. The QA Coordinator stated if the nurses found any concerns, they were responsible for contacting the physician. The QA Coordinator confirmed the admitting nurse had not completed a medication reconciliation for P19 upon admission, prior to RN1 completing one during the surveyor observed home visit. The QA Coordinator stated the agency did a mock survey in November 2024, and this was one area the agency saw as an area of concern. The QA Coordinator expressed concern about P19’s admission having occurred 19 days earlier and the need for a medication reconciliation so these issues could have been corrected before now.”

“Based on observation and interviews, the agency failed to ensure personnel followed appropriate infection prevention and hand hygiene while providing personal care for 1 of 1 patients (Patient (P)11) observed during a home visit. This deficient practice had the potential to increase the risk of infection for every patient for whom the staff member provided care. P11’s “Patient Information Report” indicated the patient was admitted to hospice services on 01/26/2023 with a diagnosis of multiple sclerosis (MS). During a home visit on 01/29/2025 at 9:30 AM, Certified Nursing Assistant (CNA)1 was observed completing a bed bath and catheter care for P11.CNA1 washed their hands, put on gloves, and gathered supplies. The CNA removed P11’s clothing, including a soiled brief, and tucked it all under P11’s buttocks.CNA1 washed P11’s upper body and then washed P11’s lower body.Wearing the same gloves, CNA1 obtained a towel and dried P11. The CNA assisted the patient to roll over onto their right side. The CNA removed the tucked brief from underneath the patient.CNA1 obtained a package of wipes and wiped P11’s buttocks as the patient had had a small bowel movement. Wearing the same gloves, the CNA washed P11’s back upper half and lower half of their body and dried the same areas.CNA1 applied cream to P11’s bottom and put on a clean brief. The CNA assisted P11 to roll over onto their back.CNA1 took another washcloth from the basin and completed P11’s catheter care wearing the same gloves. CNA1 donned a new pair of gloves and applied lotion all over P11’s body. CNA1 then dressed P11 and got the patient up into their motorized wheelchair. During an interview on 01/29/2025 at 10:45 AM, CNA1 indicated they should have changed gloves multiple times when going from a dirty to clean to clean area.CNA1 confirmed not changing gloves and stated they usually did and just did not know what happened this time.During an interview on 01/30/2025 at 3:58 PM, the Interim ED indicated CNA1 should have changed gloves multiple times and especially when going from a dirty to clean area.”

“Based on record review, interviews, and policy review, the agency failed to ensure that 2 of 6 employees (Medical Director and Certified Nursing Assistant (CNA)1) whose employee files were reviewed had a two-step tuberculosis (TB) test upon hire. This failure had the potential to lead to unnecessary treatment and adverse outcomes for 84 patients. Findings include: Review of the agency’s policy, “Staff Screening, New Hire and Annual,” revised 11/01/2024, indicated, “. . . No previous Tuberculin Skin Test (TST) . . . two-step baseline TST or Interferon-Gamma Release Assay (IGRA), previous negative TST result (documented or not) greater (than) 12 months before new employment . . . two-step baseline TST or IGRA, previous documented negative TST result less than 12 months before new employment . . . two-step baseline TST or IGRA.”1. Review of the Medical Director’s employee file indicated their date of hire was 11/03/2024. Review of the “Employee Tuberculosis Screening Form,” dated 11/26/2024, revealed the Medical Director had no documented evidence a two-step TB test completed upon hire. During an interview on 01/30/2025 at 2:45 PM, the Business Office Manager (BOM) confirmed that when a new employee was hired, their information was put into the electronic health record (EHR), and a report was generated every quarter. The BOM confirmed there was no monitoring system to ensure the TB tests were completed as ordered until the BOM began keeping track using a personal calendar.At 3:30 PM, the BOM confirmed there was no further information to show that the Medical Director had the two-step TB test. 2. Review of CNA1’s employee file indicated their date of hire was 03/13/2023. Review of the agency-provided document, “[name of outside pharmacy],” dated 02/01/2023, indicated CNA1 was given a first-step TB test which was read as negative on 02/03/2023.Review of the agency’s “Employee Tuberculosis Screening Form,” dated 04/06/2023, indicated a second step TB test was given to CNA1 on 04/06/2023; however, there was no documented evidence the TB test was read. During an interview on 01/30/2025 at 3:30 PM, the BOM confirmed CNA1’s second TB test was not conducted in a timely manner and there was no documentation indicating the TB test was read.During an interview on 01/30/2025 at 3:42 PM, the Interim ED indicated not being aware of what the process had been, but that when new hires come to the agency now, they have a TB test completed right away, and then one week later, they have the second one.”

“Based on record review, interview and policy review, the agency failed to ensure a face-to-face encounter was completed prior to recertification as required for 1 of 19 sampled patients (Patient (P) 5). This deficient practice prevented the patient from being evaluated to determine if certain criteria were met and if continued hospice care was appropriate. Findings include: Review of the agency’s policy, “Certification of Terminal Illness,” revised 04/01/2022, indicated, “. . . Beginning with the hospice patient’s third benefit period, in addition to existing certification of terminal illness requirements, the hospice Medical Director (or hospice physician member of the Interdisciplinary Group) or nurse practitioner (NP) employed by the hospice agency must have a face to face visit encounter with the hospice patient prior to the end of the benefit period . . . The face-to-face encounter may occur on the first day of the given benefit period and still be considered timely . . .”Review of P5’s “Patient Information Report” indicated the patient was admitted to hospice services on 01/09/2023 with a diagnosis of acute pancreatitis. P5 entered the hospice agency in their seventh certification period. Review of P5’s entire electronic health record (EHR) indicated no evidence a face-to-face encounter was completed prior to P5’s admission. It was recorded that the first face-to-face visit for P5 occurred on 05/10/2023. During an interview on 01/29/2025 at 5:11 PM, the Interim Executive Director (ED) confirmed P5 entered this hospice agency in their seventh certification period; however, the EHR indicated this was the first certification period for P5.The ED confirmed P5 should have received a face-to-face visit prior to admission.”