Procare Hospice of Nevada, LLC

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview and personnel record review. In 5 of 18 (28%) staff records reviewed, the agency did not ensure that staff, including contracted staff received emergency preparedness plan education at least every 2 years. Document 8: Agency’s Emergency Preparedness Program - Training and Testing Policy (AD.E13 effective 06/09/2021 and revised on 06/12/2024) stated, in part, “The hospice training program must document... emergency preparedness training at least every two years.” Personnel Record 6: A review of the personnel record of this registered nurse, who was hired on 08/12/2019 and provided care in the home hospice program, revealed no evidence of completion of emergency preparedness training in 2022, 2023, and thus far in 2024. Personnel Record 10: A review of the personnel record of this hospice aide, who was hired on 11/15/2021 and provided care in the agency’s IPU, revealed no evidence of completion of emergency preparedness training in 2022, 2023, and thus far in 2024. Personnel Record 13: A review of the personnel record of this medical director, who was hired on 01/23/2020 and oversaw care for the overall hospice program, revealed no evidence of completion of emergency preparedness training in 2022, 2023, and thus far in 2024. Personnel Record 14: A review of the personnel record of this contracted hospice physician, who oversaw care in the agency’s IPU, revealed no evidence of completion of emergency preparedness training in 2022, 2023, and thus far in 2024. Personnel Record 17: A review of the personnel record of this administrator/director of clinical operation, who was hired on 05/18/2021 and oversaw operations of the overall hospice program, revealed no evidence of completion of emergency preparedness training in 2022, 2023, and thus far in 2024. In an interview with the Human Resources Manager on 08/07/2024, she confirmed that no evidence of completion of emergency preparedness plan training was present in the personnel records of the identified staff, including contracted staff, for the time periods identified. In an interview with the Administrator/Director of Clinical Operations on 08/08/2024, she confirmed that no evidence of completion of emergency preparedness plan training was present in the personnel records of the identified staff, including contracted staff, for the time periods identified.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. A review of the fire drill logs for the agency’s IPU revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which required “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.” Document 5: A review of the fire drill logs for the IPU revealed that fire drills were held on 01/26/2023 (day shift), 05/17/2023 (day and night shift), 08/09/2023 (day shift), 04/09/2024 (day shift), and 04/11/2024 (night shift). There was no evidence of fire drills held for the following periods: third quarter of 2022 for both the day and night shifts, fourth quarter of 2022 for both the day and night shifts, first quarter of 2023 for the night shift, third quarter of 2023 for the night shift, fourth quarter of 2023 for both the day and the night shifts, and first quarter of 2024 for both the day and the night shifts. In an interview with the Administrator/Director of Clinical Operations on 08/07/2024, she stated that she believes that additional drills were held but did not have any documentation to attest to attendance or when those drills may have been held. She agreed that the logs reviewed were the only documentation of fire drills held. A review of the fire drill logs for the agency’s IPU revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which required “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.””

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 4 of 26 (15%) clinical records reviewed revealed the agency did not ensure that the interdisciplinary team completed their initial comprehensive assessments within the 5-day requirement. Clinical Record 2: The election of the hospice benefit occurred on 10/04/2023. The initial nursing assessment, documented on 10/04/2023 included a psychosocial assessment with documentation that the medical social worker (MSW) was requested to evaluate the patient. The initial plan of care orders included an order for the MSW to evaluate the patient between 10/04/2023 and 10/09/2023. The initial MSW visit was documented on 10/13/2023 (9 days after the election of hospice care). The clinical record did not contain documentation as to why the visit was not made within the 5-day requirement. Clinical Record 11: The election of the hospice benefit occurred on 12/01/2023. The initial nursing assessment, documented on 12/01/2023 included a spiritual assessment with documentation that the chaplain was requested to evaluate the patient. The initial spiritual assessment was documented on 12/21/2023 (20 days after the election of hospice care). The clinical record contained a ‘prep note’ dated 12/21/2024, that stated, “Late initial assessment: initial assessment is late because the patient had shingles. When shingles was no longer contagious, chaplain was out on bereavement leave.” The administrator (personnel record #17) stated, “we have five other chaplains that could have seen this patient, the assessment did not need to be late.” Clinical Record 13: Election of the hospice benefit occurred on 06/20/2024. The initial nursing assessment, documented on 06/20/2024 included a spiritual assessment with documentation that the chaplain was requested to evaluate the patient. The initial spiritual assessment was completed on 07/09/2024 (19 days after the election of hospice care) and stated, “this assessment is late due to the fact that this spiritual counselor was on a one-week vacation when the name of this patient came out.” Clinical Record 14: Election of the hospice benefit occurred on 06/23/2024. The initial nursing assessment, documented on 06/23/2024 included a spiritual assessment with documentation that the chaplain was requested to evaluate the patient. The initial spiritual assessment was completed on 07/11/2024 (18 days after the election of hospice care) when the patient was in the in-patient facility for respite care (07/11/2024-07/16/2024). The record did not contain documentation to support why the initial spiritual care assessment was not completed within the 5-day requirement. During an interview, on 08/08/2024, the Administrator/Director of Clinical Operations reported that there was no additional information to provide to indicate why the above psychosocial and spiritual assessments were not completed timely and stated that “there is always someone assigned as a back-up if someone is off, even on the weekends we have coverage.””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 5 of 18 (28%) personnel records reviewed revealed the agency did not ensure the annual infection control education, which is required per the agency’s policy, was provided to hospice staff. Document 10: The agency’s Infection Control - Education Policy (PC.I20 effective 06/09/2021) stated, in part, “training is provided at no cost to the employee during staff orientation and annually thereafter.” Personnel Record 6: A review of the personnel record of this registered nurse, who was hired on 08/12/2019 and provided care through the home hospice program, revealed no infection control education completion in 2022, 2023, and thus far in 2024. Personnel Record 10: A review of the personnel record of this hospice aide, who was hired on 11/15/2021 and provided care at the agency’s in-patient unit (IPU), revealed no infection control education completion in 2022, 2023, and thus far in 2024. Personnel Record 13: A review of the personnel record of this medical director, who was hired on 01/23/2020 and oversaw care over all clinical programs, revealed no infection control education completion in 2022, 2023, and thus far in 2024. Personnel Record 14: A review of the personnel record of this contracted hospice physician, who oversaw care in the agency’s IPU, revealed no infection control education completion in 2022, 2023, and thus far in 2024. Personnel Record 17: A review of the personnel record of this administrator/director of clinical operations, who was hired on 05/18/2021 and oversaw the administration of the entire hospice program, revealed no infection control education completion in 2022, 2023, and thus far in 2024. In an interview with the Human Resources Manager on 08/07/2024, she confirmed that there was no evidence of completion of annual infection control education of the listed staff members and contracted staff for the time periods identified. In an interview with the Administrator/Director of Clinical Operations on 08/08/2024, she confirmed that there was no evidence of completion of annual infection control education of the listed staff members and contracted staff for the time periods identified.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) clinical records reviewed, in which the patient received wound care, revealed the agency did not ensure adherence to the wound care policy by the nursing staff. Document 4: PC. W10 Wound Care policy (last reviewed 07/26/2024) stated in relevant parts, “The admitting clinician will document each wound status including, location and etiology, measurement of length, width and depth, undermining and tunneling if present, description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. Each wound will be assessed and documented, on each visit.” Clinical Record 10: The patient elected the hospice benefit on 06/21/2024 with a diagnosis of Parkinson’s disease. The initial nursing comprehensive assessment dated 06/21/2024 documented the patient was admitted with the following wounds: Left lateral proximal outer foot stage IV, left medial proximal inner foot heel pressure ulcer unstageable, right lateral proximal outer foot arch pressure ulcer unstageable, right medial proximal inner foot heel unstageable, these wounds all had specific wound care/dressing change orders for two times per week. On 07/05/2024 the wound care orders were changed to one time per week. On 07/22/2024 a right inner foot pressure ulcer (non-staged) was documented, and on 07/23/2024 a lower inner buttocks coccyx stage II was documented, wound care orders were present for both of these wounds. The skilled nursing visit orders from 6/21/2024 to 8/6/2024 were for 2 visits per week. On 8/6/2024 the nursing visit frequency was increased to 4 times per week. Within each of the nursing assessments the wounds were documented, however, from 06/21/2024 to current date (08/08/2024) the wound assessments did not contain measurements of length, width, or depth of the wounds. On 08/08/2024 a joint record review was conducted with the Administrator/Director of Clinical Operations who confirmed that the record did not contain any documentation of wound measurements. On 08/08/2024 the Administrator/Director of Clinical Operations reported they had communicated with the RN case manager, who had been involved with this patient since 06/21/2024, and confirmed that she had not obtained wound measurements on any of these wounds.”

“It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 2 (50%) personnel records of hospice aides reviewed, the agency did not ensure the hospice aides received at least 12 hours of in-service training during each 12-month period, Document 6: Agency’s Hospice Aide In-Service Training Policy (PC.H22, effective 06/09/2021 and reviewed on 07/26/2024) stated, in part, “Hospice aides receive at least 12 hours of in-service training during each 12-month period.” Personnel Record 10: A review of the personnel record of this hospice aide who is providing care in the IPU, and who was hired on 11/15/2021, revealed there was no documented evidence of any in-service training towards the 12-hour requirement in 2023 or thus far in 2024. An interview on 08/07/2024 with the Human Resources Manager, which included a review of this hospice aide’s personnel record, confirmed there was no record of this aide receiving any in-service training in 2023 or thus far in 2024. An interview on 08/08/2024 with the Administrator/Director of Clinical Operations, which included a review of this hospice aide’s personnel record, confirmed there was no record of this aide receiving any in-service training in 2023 or thus far in 2024.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 6 (17%) contracts reviewed, there was no requirement for criminal background checks for contracted staff having access to patient records. Contract 5: In a review done on 08/06/2024 of the agency’s contract for therapy services, which is currently in effect, there was no provision requiring criminal background checks of contracted staff who have direct patient contact or access to patient records. In an interview with the Administrator/Director of Clinical Operations on 08/06/2024, she confirmed there was no provision for requiring criminal background checks within the therapy contract for the therapy supplier staff who had direct patient contact or access to patient records.”