Bristol Hospice - Las Vegas

“The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. This standard was not met as evidenced by document review and interview. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the emergency preparedness plan was tested annually as required. The agency did not participate in a full-scale exercise that was community-based exercise or conduct a mock drill of the organization’s emergency plan. DOCUMENT 1: The agency’s policy 4-001, titled Emergency Plan, dated July 2024, stated in part, “The hospice will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise.” An interview with the Regional VP of Clinical Operations was conducted on January 29, 2026, and the information was reviewed. The agency lacked documentation demonstrating that the emergency plan had been tested. She contacted others within the corporation to determine whether any documentation supported the agency’s annual testing of the emergency preparedness plan. She was unable to provide documentation and agreed with the findings. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the emergency preparedness plan was tested annually as required. The agency did not participate in a full-scale exercise that was community-based exercise or conduct a mock drill of the organization’s emergency plan.”

“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, in accordance the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure completion of the initial comprehensive assessments within five calendar days after the election of hospice care. DOCUMENT 2: The agency’s policy 1-014, titled Comprehensive Assessment, dated May 2020, stated in part, “a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care.” CLINICAL RECORD 4: The patient elected the hospice benefit on October 17, 2025. The initial comprehensive nursing assessment was completed on October 17, 2025. The initial psychosocial assessment was completed on November 7, 2025 (21 calendar days from the initial nursing comprehensive assessment). During the review of the clinical record, no documentation was found to determine the reason for the delayed psychosocial assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on January 9, 2026. The initial comprehensive nursing assessment was completed on January 9, 2026. The initial spiritual care assessment was completed on January 16, 2026 (8 calendar days from the initial nursing comprehensive assessment). During the review of the clinical record, no documentation was found to explain the delayed spiritual care assessment. An interview was conducted with the Regional VP of Clinical Operations on January 28, 2026, related to the clinical review and the delayed assessments. She stated that the issue was identified in August 2025, and a performance improvement project (PIP) has been developed to address the delayed assessment.”

“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, interview and personnel record review. In 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure a criminal background check was obtained for a contracted employee DOCUMENT 3: The agency policy 1-005-HR, titled Selection/Hiring of Personnel, dated December 2024, stated in part, “a criminal background check will be obtained for all positions.” PERSONNEL 9: The personal record revealed the contracted employee signed a contract on June 1, 2025. The record showed that a criminal background check was not conducted for the contracted employee. An interview was conducted with the Regional VP of Clinical Services on January 29, 2026. A review of the personnel record found no criminal background check before access to patient records. The personnel had provided physician orders and certification of terminal illness, and had participated in interdisciplinary group meetings over the prior seven months. She stated the background check was requested during the site visit, but agreed it was not performed prior to access to patient records.”