Otium Hospice Inc.

“Upon patient record review, 2 of 14 (Patient #12,#14) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient’s attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient 1,2,3,4,5,6,7: No evidence of IDG meetings on 04/01/26 and 04/15/26. Missing meeting documentation and IDG signatures for both scheduled meetings. There is no evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient. Patient 12,14: No evidence in medical records of collaboration or involvement with chosen attending.”

“Upon personnel record review, 2 of 13 (Personnel #2,#8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel 2: No evidence of a DPCS, RN being an employee. No evidence of a W-2 form in the personnel file. In addition, the sole RN was out of the country during the survey with no known return date and no documented coverage in place. Personnel 8: No evidence of Medical Director signing orders from admission, documenting and signing IDG meeting notes and providing F2F visits.”

“Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 13: On 2/28/24, LPN documented patient was experiencing dyspnea and excessive pain with oxygen to be delivered. New medications ordered; however, there was no evidence of oxygen ordered to be delivered or order for use of the oxygen. No evidence of follow up or visit by nurse to assess medication effectiveness or delivery of oxygen the following day 2/29/24. Patient died on 3/1/2024.”

“Upon patient record review, 3 of 14 (Patient #2,#4,#5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: Medication profile contains Atorvastatin 20mg and Metoprolol 25mg; however, patient states she no longer takes these medications. Patient states she has been taking Pioglitazone 45mg QD and Amlodipine 10mg QD with no evidence of these medications on the med profile. Patient 4: Patient has been taking Lisinopril 5mg QD; however, there was no evidence of medication on the medication profile. Patient 5: Medication profile contains the following medications that the patient is no longer taking: Gabapentin 300mg BID, Metformin 500mg QD, Tamsulosin 0.4mg QD, Tradjenta 5mg QD, Lantus 100 units QD, and Meclizine 25mg TID. Patient has been taking the following medications since 2/19/2026: Famotidine 20mg QD, ASA 81mg QD, Sodium Bicarb 650mg BID, Pregabalin 75mg BID, Rivastigmine 1.5mg BID, Omeprazole 40mg QD, Vitamin D2 1.25mg 1x/week, Losartan 25mg QD, Lantus 50 units QD, Trulicity 3mg 1x/week, Loperamide 3mg PRN, and Quetiapine 25mg BID with no evidence of these medications on the medication profile.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,6,7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Patient 1: The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/29/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN. Patient 2: The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/27/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN. Patient 3,7 The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/22/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN. Patient 4: The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/21/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN. Patient 5: The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/18/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN. Patient 6: The RN delegated the LVN to make comprehensive assessment visits which is outside the scope of practice for an LVN. The RN had not made any visits since 3/25/26. According to Arizona Administrative Code, Board of Nursing R4-19-402. a RN shall supervise, monitor, and evaluate the care assigned to a LPN.”

“Upon patient record review, 7 of 12 (Patient #1,#2,#3,#4,#5,#6,#7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: No evidence of RN visit since 3/29/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/29/26. Patient 2: No evidence of RN visit since 3/27/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/27/26. Patient 3,7: No evidence of RN visit since 3/22/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/22/26. Patient 4: No evidence of RN visit since 3/21/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/21/26. Patient 5: No evidence of RN visit since 3/18/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/18/26. Patient 6: No evidence of RN visit since 3/25/2026 with visit frequency once every 14 days. The RN is accountable for an ongoing comprehensive assessment. The LVN was the only nurse making visits and there was no evidence of documentation that the RN was collaborating with the LVN since 3/25/26.”

“Upon client record review, 2 of 14 (Patient #12,#14) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. Patient 12: On admission, patient chose FNP as attending. No evidence in medical records of communication or involvement with chosen attending. Patient 14: On admission, patient chose an attending physician. No evidence of communication or involvement with this physician.”

“Upon patient record review, 3 of 14 (Patient #2,#4,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: Patient states she no longer takes Atorvastatin 20mg and Metoprolol 25mg; however, no evidence of orders to discontinue these medications. Patient states she has been taking Pioglitazone 45mg QD and Amlodipine 10mg QD with no evidence of orders for these medications in the medical record. Patient 4: Patient has been taking Lisinopril 5mg QD; however, the medical record does not contain an order for this medication. Patient 5: Patient is no longer taking: Gabapentin 300mg BID, Metformin 500mg QD, Tamsulosin 0.4mg QD, Tradjenta 5mg QD, Lantus 100 units QD, and Meclizine 25mg TID. However, there is no evidence of orders to discontinue these medications in the medical record. Patient has been taking the following medications since 2/19/2026: Famotidine 20mg QD, ASA 81mg QD, Sodium Bicarb 650mg BID, Pregabalin 75mg BID, Rivastigmine 1.5mg BID, Omeprazole 40mg QD, Vitamin D2 1.25mg 1x/week, Losartan 25mg QD, Lantus 50 units QD, Trulicity 3mg 1x/week, Loperamide 3mg PRN, and Quetiapine 25mg BID with no evidence of orders in the medical record for these medications.”

“Upon client record review, 9 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: RN visit frequency is 1x every 14 days. No evidence of RN visit since 3/29/2026. Patient 2: RN visit frequency is 1x every 14 days. No evidence of RN visit since 3/27/2026. Patient 3,7: No evidence of RN visit since 3/22/2026. RN visit frequency is 1x every 14 days. Patient 4: No evidence of RN visit since 3/21/2026. RN visit frequency is 1x every 14 days. Patient 5: No evidence of RN visit since 3/18/2026. RN visit frequency is 1x every 14 days. Patient 6: RN visit frequency is 1x every 14 days. No evidence of RN visit since 3/25/2026. Patient 9: SN visit frequency was once weekly with only the RN making visits once every 2 weeks. Patient 10: SN frequency was once weekly with no evidence of visit the week of 8/4/2025”

“Upon patient record review, 2 of 14 (Patient #13,#14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13,14: No evidence of development of bereavement plan of care or any bereavement extended to family or other individuals.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body lacked oversight by not ensuring the appointment of a qualified Administrator. There was no documentation of Administrator selection in GB meeting minutes; the identified contracted Administrator also lacked documented education qualifications. Upon arrival to agency the personnel were unable to determine who was the appointed Administrator, organizational chart was put in the trashcan that was posted on the wall identifying the Administrator as AD. Furthermore, there was no identified Alt. Administrator for the agency. The agency failed to ensure adequate 24-hour nursing supervision, as the sole RN was unavailable without coverage, and LPN staff were providing care and updating comprehensive assessments without RN oversight, exceeding scope of practice for the LPN. The hospice also failed to ensure compliant hospice admission practices, as a patient was admitted without completed and signed election and consent documentation. Personnel and organizational compliance were deficient, with missing personnel files for multiple disciplines to include the PT/OT/ST, no evidence of annual skills competencies, observation and evaluation of direct care job performance, and job descriptions for multiple disciplines of the hospice. In addition, the Administrator, DPCS, bereavement coordinator, and volunteer, has no evidence of orientation. The agency further failed to ensure appropriate physician services, as there was no designated alternate medical director, the Medical Director was minimally involved and refused surveyor communication, and oversight was limited to signing certifications of terminal illness. In addition, the hospice failed to ensure an effective interdisciplinary group process, as IDG meetings did not include full required discipline participation or evidence of coordinated care addressing physical, medical, psychosocial, emotional, and spiritual needs of the hospice patient, and there was no documented collaboration with attending physicians when elected by the patient.”

“Upon observation, there was no evidence that the following services are made routinely available on a 24-hour basis 7 days a week. • Nursing services • Physician services • Drugs and biologicals • Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. No evidence of RN availability 24/7, as RN out of the country. There was a second RN with personnel file; however, Administrator and Office Manager state they have been unsuccessful in reaching her via phone. Attempt to reach her during survey was unsuccessful. Also, attempt to reach Medical Director via phone during survey was unsuccessful.”

“Upon patient client record review, 7 of 14 (Patient #1,#2,#3,#4,#5,#6,#7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1,4: 4/6/2026 LPN visit documentation was found to be incomplete, with missing narrative and assessment components. Patient 2,5: LPN documentation from visit on 4/8/2026 is incomplete with no evidence of assessment details and narrative. Patient 3,6: 4/7/2026 LPN visit documentation was found to be incomplete, with missing narrative and assessment components. Patient 7: RN completed supervisory visits every 14 days for aide Angie Gomez; however, patient had declined aide services upon admission. Also, LPN documentation from visit on 4/9/2026 is incomplete with no evidence of assessment details and narrative.”