Desert Haven Hospice, LLC

EP Training Program (42 CFR 418.113(d)(1)(iii))

“Observed in Competency Session. On review of all HR records, there was no documentation to validate staff were provided emergency management training on hire. This was reviewed and validated in discussion hospice leadership.”

Rule E0037. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Observed in Record Review. In 2 out of 2 bereaved patient records reviewed, the organization failed to complete a bereavement risk assessment after the death of the patient. Organization’s Bereavement Policy states that the Bereavement Risk assessment is completed during first IDG after the patient’s death. On RRBR #1 and RRBR #2, it was noted the organization did not complete a bereavement risk level for the patient after their death. This finding was discussed with Hospice leadership.”

Rule L0531. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Observed in Record Review. On 1 of 2 live discharge records reviewed, the organization did not obtain orders for discharge from the Hospice. On RRDC #1, the patient was transferred to another hospice but there was no written physician order for that discharge from the agency. This finding was reviewed with Hospice leaders.”

Rule L0547. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

Rule L0549. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

Rule L0550. Standard-level.

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

“Observed in Record Review. In 1 of 6 patient records reviewed, the Interdisciplinary team (IDG) did not review the plan of care at least every 15 days. On RRHV #1, the first IDG occurred 18 days after admission. This finding was reviewed with Hospice leadership.”

Rule L0552. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Data Session. During QAPI session, it was noted the organization did not have documented hand hygiene goals for 2025 and subsequently, no data regarding improvements in hand hygiene compliance. This was reviewed with the administrator.”

Rule L0581. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(iv))

“Observed in Record Review. In 2 of 2 bereavement records reviewed, it was noted that the organization had not ensured it developed a bereavement plan of care that specified the type of bereavement services to be offered. On review of RRBR #1 and RRBR #2, the post death bereavement plan of care was not developed. This finding was reviewed with Hospice leadership.”

Rule L0596. Standard-level.

Counseling services (42 CFR 418.64(d)(3)(i))

“Observed in Record Review. On 2 of 4 active patient records reviewed, the organization did not completed a comprehensive spiritual assessment on admission. Agency policy states that on admission spiritual/cultural practices that include desired religious group, spiritual concerns or needs are addressed. On RRHV #2 and RRNHV #1, the nurse documented No to assessment of spiritual concerns and no chaplain was ordered. This finding was reviewed with Hospice leadership.”

Rule L0598. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

Rule L0629. Standard-level.

Professional management responsibility (42 CFR 418.100(e)(1))

“Observed in Tracer Activities. On review of agency contracts, the organization did not have stipulations within the contract that included all required elements. On review of the pharmacy contract and therapy contract, the contract did not specify that services are provided only with authorization of hospice, serviced delivered in accordance with plan of care, and manner to coordinate with hospice. Agency was able update the therapy contract during the survey week. This finding was reviewed with Hospice leadership.”

Rule L0655. Standard-level.

Training (42 CFR 418.100(g)(2))

“Observed in Competency Session. On review of all HR files, there was no documentation available to show that an orientation occurred. The organization has orientation binders with all the information of the orientation that they review but have not been documenting that the training occurred. This was reviewed and validated in discussion hospice leadership.”

Rule L0662. Standard-level.

Criminal background checks (42 CFR 418.114(d)(1))

“Observed in Tracer Activities. On review of agency contracts, the organization did not have stipulations within the contract that included all required elements. On review of the pharmacy contract and therapy contract, the contract did not specify the completion of background check for employees who provide direct patient care or have access to patient record. This finding was reviewed with Hospice leadership.”

Rule L0795. Standard-level.