Jireh Healthcare Services, LLC

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During the Volunteer Program discussion with the DON/Administrator/Volunteer Coordinator it was noted that there had not been recruitment activity or retention activity documented for 2022, 2023, or 2024. The organization stated that they had put up an ad for volunteers on Indeed and Vegas Healthcare Social Media 2 days ago and stated that in the past they have provided lunch and gas cards for the volunteers. However there was no documentation of the activities discussed.”

Rule L0645. Standard-level.

Training (42 CFR 418.100(g)(3))

“Observed in HR File Review. During review of the Administrator/DON/Volunteer Coordinator HR file it was noted that the organization had not assessed and documented competencies annually per their policy. For example, the Volunteer Coordinator had documented annual competencies for 2022, 2023, 2024 however the 2023 competency dated 8/25/23 did not have an observer signature, only the Volunteer Coordinator. Also, there were no documented competencies for the Director of Nursing for 2022, 2023, 2024. This was discussed with the DON.”

Rule L0663. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who also serves as Volunteer Coordinator, it was noted that there has not been an active volunteer program and, therefore, no recruitment activity for years 2022, 2023, an 2024. This was verified by the Director of Nursing/Administrator.”

Rule L0645. Condition-level.

Cost saving (42 CFR 418.78(d)(3))

“Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who serves as the Volunteer Coordinator, surveyor noted that the hospice had not had an active volunteer program since 2021. Therefore, there was no cost savings documentation. This was verified by the Director of Nursing/Administrator.”

Rule L0646. Condition-level.

Level of activity (42 CFR 418.78(e))

“Observed in Tracer Activities. During the Volunteer Program discussion with the Director of Nursing/Administrator who serves as the Volunteer Coordinator, surveyor noted that noted that there has not been an active volunteer program for years 2022, 2023, an 2024, therefor, the organization had not achieved at least a 5 % cost savings through the use of volunteers. This was verified by the Director of Nursing/Administrator.”

Rule L0647. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Tracer Activities. During the Volunteer Program discussion with the CEO and Administrator/Director of Nursing, surveyor noted that the organization did not implement volunteer program resulting in a condition level deficiency.”

Rule L0651. Condition-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Review of the plan of care (42 CFR 418.56(d ))

“Observed in Record Review. In 1of 7 record reviews, surveyor observed that the IDG team failed to review and revise the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. For example, in RRHV#1, 28 calendars days had passed between IDG plan of care review and revision. This was verified with the Director of Nursing/Administrator.”

Rule L0552. Standard-level.

Prevention (42 CFR 418.60(a))

“Observed in Patient Home. In 2 of 3 home visits, surveyor observed that the nurse donned gloves to assess patients’ skin and take patients’ vital signs for BP, pulse, and temperature, however, the nurse did not remove gloves after providing care and proceeded to clean the equipment used and placed the cleaned equipment back into the bag using the same gloves. This was reviewed with the Director of Nursing/Administrator.”

Rule L0579. Standard-level.

Training (42 CFR 418.100(g)(3))

“Observed in HR File Review. During the Competency Review Session, in 2 of 10 HR files reviewed, surveyor noted that the organization had not assessed and documented competencies annually per their policy. For example, the Volunteer Coordinator and Director of Nursing did not have annual competencies for 2022, 2023, and 2024. This was verified by the Administrator/Director of Nursing.”

Rule L0663. Standard-level.

Content (42 CFR 418.104(a)(7))

“Observed in Patient Home. In 1 of 3 home visits, during review of the medication reconciliation process performed by the nurse at the request of the surveyor, surveyor noted the frequency for the medication Albuterol Sulfate solution on the MAR was written to administer every 6 hours as needed; however, the frequency on the medication container was written to administer every 8 hours as needed. This was reviewed with the Director of Nursing/Administrator.”

Rule L0678. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(6))

“Observed in Patient Home. During review of the contract for DME, the surveyor observed that the leaders had not communication of the expectations for providing emergency backup oxygen for patients on oxygen. This was evidenced by in 3 of 3 home visits, surveyor observed that patients were utilizing oxygen via O2 concentrators, however, there were no back up oxygen tanks present in either of the patients’ homes. This was verified with the Administrator/Director of Nursing. 

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Rule L0716. Standard-level.