Atlas Hospice of Southern Utah

“Based on record review and interview, the hospice agency failed to ensure that an initial social worker (SW) assessment was completed for two patients (Patient (P) 1 and P10) and failed to ensure an initial spiritual assessment was completed for one patient (P3) within five days after the election of hospice care, out of a sample of 14 patients. Findings include: 1. Review of P1s agency provided “Patient Profile” indicated that P1 was admitted to hospice on 11/04/24 with a diagnosis of congestive heart failure. Review of P1s facility provided “Social Worker Assessment,” dated 11/11/24 (seven days after the election of hospice care) indicated the assessment was completed late. During an interview with the Administrator on 12/18/24 at 1:00 PM, he confirmed the lateness of the initial assessment and indicated that it should have been completed by the fifth day. 2. Review of P10s agency provided “Patient Profile” indicated that P10 was admitted to hospice on 10/12/24 with a diagnosis of lung cancer. Review of P10s facility provided “Social Worker Assessment,” dated 10/20/24 (eight days after the election of hospice care) indicated the assessment was completed late. During an interview with the Administrator on 12/18/24 at 12:55 PM, he confirmed the lateness of the initial assessment. 3. Review of P3s agency provided “Patient Profile” indicated that P3 was admitted to hospice on 11/15/24 with a diagnosis of senile degeneration of the brain. Review of P3s facility provided “Chaplain/Counselor Assessment,” dated 11/21/24 (six days after the election of hospice care) indicated the assessment was completed late. During an interview with the Administrator on 12/18/24 at 12:58 PM, he confirmed that the assessment was late and should have been completed within five days.”

“Based on record review and interview, the hospice agency failed to ensure that one of 14 (Patient (P) 3) sampled patients had their medications reconciled from the Assisted Living Facility (ALF) to match the medications that the hospice agency had ordered. This deficient practice had the potential to affect the accuracy of medications ordered for P3. Findings include: Review of P3s agency provided “Patient Profile” indicated that P3 was admitted to hospice on 11/15/24 with a diagnosis of senile degeneration of the brain. Review of P3s “[name of ALF] Active Medication” indicated, “Aspirin [nonsteroidal anti-inflammatory medication] chewable tablet 81 milligram (mg), daily starting 10/03/24; losartan 100 mg [blood pressure medication] give one tablet by mouth (PO) daily, starting 10/13/24; and Vitamin D2 [vitamin], 50 microgram (mcg) (2000 unit) weekly, take one capsule PO every week, starting 10/11/24.” Review of the agency provided “Medication Profile,” dated 11/15/24-02/12/25 indicated, “Aspirin 325 mg one tab PO daily starting 11/15/24.” There was no evidence of vitamin D2 and losartan. Interview on 12/18/24 at 12:50 PM, the Administrator indicates that the medications are to be reconciled each visit and confirmed the hospice agency and the ALFs medications did not match and should have.”

“Based on record review, interview, and policy review, the facility failed to update the plan of care related to oxygen use for two (Patients (P) 5 and P3) of 10 active patients reviewed for plans of care out of a total sample of 14 patients. This had the potential for the patients to experience unmet care needs. Findings include: Review of the agencys policy titled, “Interdisciplinary Group (IDG),” dated April 2020, indicated, “...The interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care that will allow for measurement of outcomes. The IDG demonstrates a proactive approach in developing each patients plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than solely a response to a crisis... to provide coordination of care and to ensure continuous assessment of each patients and familys needs and implementation of the interdisciplinary plan of care.” 1.Review of P5’s “Patient Profile” located in the electronic medical record (EMR) under the “Patient Profile” tab revealed P5 was admitted to Hospice services on 11/12/24 with a terminal diagnosis of malignant neoplasm (cancer) of unspecified part of unspecified bronchus or lung. Review of P5’s “Plan of Care” dated 11/12/24 and located in the EMR under the “IDG/POC” tab revealed there were no orders for oxygen or a respiratory care plan. Review of P5’s “Skilled Nursing Note” dated 12/11/24 and located in the EMR under the “RN” tab revealed P5 was a little more anxious with increased shortness of breath (SOB). The patient reported his oxygen had dropped a little at night and he/she said they were having difficulty falling asleep. The patient and care giver requested oxygen. The oxygen was ordered, and the patient will be using the oxygen at night and if needed during the day. Review of P5’s “Physician Order” dated 12/11/24 and located in the EMR under the “Medication Profile” tab revealed an order for oxygen via nasal canula at 2 liters per minute (lpm) for SOB or comfort. There was no evidence in P5’s EMR that the plan of care was updated to reflect the new order for oxygen for P5. During an interview on 12/18/24 at 3:20 PM the Administrator confirmed P5 was ordered oxygen on 12/11/24 and there was no update to the patient’s plan care related to respiratory/oxygen use and there should have been an update. 2. Review of P3s agency provided “Patient Profile” indicated that P3 was admitted to hospice on 11/15/24 with a diagnosis of senile degeneration of the brain. During home visit observation with Registered Nurse (RN) 3 on 12/17/24 at 9:23 AM, P3 was observed in his/her bed with oxygen being administered at 2 lpm via nasal cannula. Review of the agency provided “Interdisciplinary Group (IDG) Meeting,” dated 12/09/24, indicated no evidence P3s use of oxygen was included in the care plan. During an interview on 12/18/24 at 12:50 PM, the Administrator indicated that there should have been a care plan for P3s use of oxygen however, oxygen use was not included in the care plan.”

“Based on record review and interview, the Hospice Agency failed to ensure that care plans for all patient problems were created for two of 10 (Patient (P) 4 and P6) active sampled patients out of a total sample of 14. This deficient practice had the potential to affect the patients quality of life. Findings include: 1. Review of P4’s “Skilled Nursing Visit,” dated 12/12/24, 12/05/24, 12/03/24, 11/27/24, and 11/25/24 and found in P4’s Electronic Medical Record (EMR) under the “Nursing” tab, indicated P4 was “short of breath with minimal exertion or with agitation” and used two liters of supplemental oxygen as needed. Review of P4’s “Plan of Care - Problems,” dated 12/12/24, 12/05/24, 12/03/24, 11/27/24 and 11/25/24 and found in P4’s EMR under the “Care Plan” tab, indicated no care plan was started to include shortness of breath and supplemental oxygen use. 2. Review of P6’s “Skilled Nursing Visit,” dated 12/27/24, and 12/17/24 and found in P6’s EMR under the “Nursing” tab, indicated that P6 “reports nausea and vomiting with increased dizziness.” Review of P6’s “Plan of Care - Problems,” dated 12/27/24 and 12/17/24 and found in P6’s EMR under the “Care Plan” tab, indicated no care plan was started to include nausea, vomiting and dizziness. During an interview on 12/17/24 at 3:30 PM, the administrator confirmed that a care plan should have been opened for nausea, vomiting and dizziness. The administrator advised that the agency does not have a policy developed to address care plans.”

“Based on policy review, record review, and interview, the hospice agency failed to provide appropriate symptom management for one of 10 (Patients (P) 4) active sampled patients reviewed out of a total sample of 14. This deficient practice had the potential to affect the patient’s quality of life. Findings include: Review of P4’s “Skilled Nursing Visits,” dated 11/21/24, 11/25/24, 11/27/24, 12/03/24, 12/05/24, 12/10/24, and 12/12/24 and located in the Electronic Medical Record (EMR) under the “Nursing” tab, indicated that P4’s diagnosis was senile degeneration of the brain. The Registered Nurse (RN) documented in the skilled nursing notes that P4 had “SOB (shortness of breath) with minimal exertion or with agitation, was “agitated during the day and often refuses cares and meals when offered by assisted living facility,” and “c/o (complained of) feeling sore all over when asked about pain.” There was no documentation indicating that the RN offered medications for P4’s shortness of breath, pain, or agitation or notified the Medical Director about the unmanaged symptoms. During an interview on 12/17/24 at 3:20 PM, the Administrator confirmed that the RN’s documentation indicated that P4 had unresolved symptoms and there was no documented evidence that interventions were provided. Review of the agency’s policy titled, “Pain and Symptom Management,” dated April 2020, indicated “Pain and symptom management is essential in providing the highest quality of care for hospice and palliative patients . . . The resolution of pain and symptoms will be dealt with promptly for the patient’s comfort.””

“Based on documentation review and interview, the hospice agency failed to ensure two of two (Certified Nursing Assistants (CNA) 1 and CNA 2) received the required 12 hours of annual training. This deficient practice had the potential to cause harm to patients’ receiving CNA services. Findings include: Review of the agency’s documentation titled, “CNA In-services” indicated that CNA1 and CNA2 received hospice aide training; however, there was no documentation of the number of hours it took to complete each training course. During an interview on 12/18/24 at 3:00 PM, the Administrator confirmed that there was no documentation indicating how many hours of training the CNAs receive annually. The Administrator advised that the agency did not have a policy developed regarding CNA required hours of training.”

“Based on observation, record review, and interview, the hospice agency failed to obtain a physician order for two patients (Patients (P) 3 and P9) from 10 active patient records reviewed. P3 did not have an order for oxygen and P9 did not have an order for how often to change his/her indwelling urinary catheter. This failure has the potential to affect the coordination of care for the patients. Findings include: 1. Review of P3s agency provided “Patient Profile” indicated that P3 was admitted to hospice on 11/15/24 with a diagnosis of senile degeneration of the brain. During home visit observation with Registered Nurse (RN) 3 on 12/17/24 at 9:23 AM, P3 was observed in his/her bed with oxygen being administered at 2 liters per minute via nasal cannula. Interview with RN3 on 12/17/24 at 9:52 AM, indicated that P3s oxygen saturation levels were low at night one week ago, so the oxygen was applied at 2 liters per minute. Review of the agency provided “Medication Profile,” dated 11/15/24-02/12/25, indicated no evidence of an oxygen order. During an interview on 12/18/24 at 12:50 PM, the Administrator indicated that there should have been an order for the oxygen and confirmed that there was not. 2. Review of P9’s “Skilled Nursing Visit,” dated 10/31/24 and located in the Electronic Medical Record (EMR) under the “Nursing” tab indicated that P9’s indwelling urinary catheter (thin, flexible tube inserted into the urethra and bladder to drain urine continuously) was changed today. Review of P9’s “Medication Profile” provided by the facility revealed no physician order for how often to change the indwelling urinary catheter. During an interview on 12/18/24 at 12:45 PM, the Administrator confirmed there was no physician’s order for how often P9’s indwelling urinary catheter.”