Facility Evaluation Report

At 8 :00 a.m. on 12/20/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit for complaint # 31-AS-20230821153401. LPA met with Staff #1 (S1) and later the administrator at approximately 8:30 a.m. and disclosed the reason for the visit.

During the course of investigation, other deficiencies were discovered in the facility. Therefore, this case management visit was conducted to address the deficiencies discovered.

During a record review at 8:15 a.m. today, it was discovered that Resident #1 (R1) and Resident #2 (R2) were enrolled in hospice services on 07/07/2023 and 06/21/2023. The plans of care were signed by a registered nurse, a medical social worker, a spiritual counselor, and a medical director, but were not signed by the licensee, R1, R2, or their responsible parties. This deficiency is cited on the attached LIC 809-D page.

Records detailing facility personnel duties, hospice visits, and personnel trainings were not maintained or included in hospice records in the facility. Resident #3 (R3) and Resident #4 (R4) are enrolled in hospice services but did not have hospice care plans maintained in the facility. The administrator contacted the hospice agency for the care plans at 9:00 a.m. today. This deficiency is cited on the attached LIC 809-D page.

Roommate acknowledgements of hospice services for R1, R2, R3, and R4 were not maintained or available at the facility. This deficiency is cited on the attached LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.