Oc Hospice

“Based on interview and record review, the hospice failed to ensure the patient and PCG were advised of the accurate information for filing a complaint for three or three sampled patients (Patients 1, 2, and 3). This failure had the potential risk of violating the patient’s rights to be informed of the accurate information for filing a complaint to these patients.Findings: Review of the hospice’s P&P titled Patient Rights and Responsibilities undated showed patient rights included the right to access the State home health and hospice care-toll free hotline. This hotline is available on a 24-hour basis to receive complaints and questions regarding hospice.Review of the hospice’s admission packet was initiated on 3/25/26. The admission packet indicated the Procedure for Making Complaints.However, the listed 24-hour tollfree number was not a working number. In addition, the address to file for complaints was incorrect. a. Review of Patient 1’s clinical record was initiated on 3/25/26, and showed the PCG signed the Informed Consent and Treatment Authorization dated 11/21/23, with the inaccurate 24-hour tollfree number and address.b. Review of Patient 2’s clinical record was initiated on 3/25/26, and showed the PCG signed the Informed Consent and Treatment Authorization dated 1/15/25, with the inaccurate 24-hour tollfree number and address.c. Review of Patient 3’s clinical record was initiated on 3/26/26, and showed the patient signed the Informed Consent and Treatment Authorization dated 12/2/25, with the inaccurate 24-hour tollfree number and address.On 3/25/26 at 1038 hours, an interview was conducted with the Administrator. The Administrator confirmed the 24-hour tollfree hotline and address to file a complaint was incorrect.”

“Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 1). This failure had the potential for the patient not receiving the appropriate care and necessary services that could negatively affect the patient’s well-being. The hospice’s P&P titled Medication Regimen Review undated showed the medication profile is part of the patient-specific comprehensive assessment. A Registered Nurse creates and maintains a current medication profile and reviews all patient medications, both prescription and non-prescription, on an on-going basis in collaboration with other interdisciplinary group members.Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The Current Medication List showed the patient’s medications included the following:-morphine sulfate IR (opioid analgesic) 20 mg/ml 0.5 ml orally every two hours as needed for moderate pain.-morphine sulfate IR 20mg/ml 1 ml orally every two hours as needed for severe pain.-morphine sulfate IR 20 mg/ml 1 ml orally every two hours as needed for severe respiratory distress.-Duoneb 3 mg-0.5 mg/3 ml (broncholdilator) one unit via respiratory inhalation three times a day as needed for wheezing/shortness of breath.-Calmoseptine (topical ointment) 0.44% one inch topically, re-apply every time incontinence care is provided as needed to prevent excoriation.-aspirin (nonsteroidal anti-inflammatory drug) 81 mg enteric coated one tablet orally once daily as preventative measure for stroke.A joint home visit with HA 1 was conducted on 3/26/26 at 1040 hours, to the patient’s home.Review of the patient’s medications at Patient 1’s home with HA 1 and the PCG showed the following:-morphine sulfate IR 20mg/ml 1 ml orally every two hours routinely for moderate to severe pain. The PCG checked the indication for the medication and confirmed it was to be given routinely.-Duoneb 3 mg-0.5 mg/3 ml one unit via respiratory inhalation three times a day as needed for wheezing/shortness of breath was not used by the patient as confirmed by the PCG.-Calmoseptine 0.44% one inch topically, re-apply every time incontinence care is provided as needed to prevent excoriation was not used by the patient as confirmed by the PCG. The PCG stated the hospice provided Phytoplex Protectant-guard Paste (topical cream) to be used to prevent excoriation.-aspirin 81 mg enteric coated one tablet orally once daily as preventative measure for stroke. The PCG stated the aspirin medication was discontinued a month ago.On 3/27/26 at 1027 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director acknowledged the above findings.”

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement in the patients’ health conditions. Review of the hospice’s P&P titled Plan of Care undated, showed the content of the plan of care. The hospice will develop an individualized written plan of care for each patient which will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:a.Start of care dateb.Certification periodc.Patient demographicsd.Principle diagnosis and other pertinent diagnosese.Medications: dose/frequency/routef.Allergiesg.Orders for specific hospice and palliative care services and disciplines, treatments, procedures (specify amount/frequency/duration)h.Interventions to manage pain and symptomsi.Equipment and supply needsj.Family needsk.Spiritual needsl.End-of-life care preferencesm.Bereavement needsn.Patient goals/outcomeso.Functional limitationsp.Diet and nutritional needsq.Anticipated discharge needsr.And safety measures1.Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.Review of the RN Visit Note dated 3/24/26, showed the PCG reported the patient had a rash on the left armpit which was itching. The physician was notified and ordered Miconazole Nitrate 2% (antifungal topical powder).The POC/IDG Review dated 3/25/26, showed a new wound care treatment order started on 3/18/25, for the left armpit rash: cleanse with water and mild soap, pat dry, apply Miconazole Nitrate 2% lightly to the affected area twice daily, PRN if needed.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s left armpit rash.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS and QAPI Director. The DPCS and QAPI Director confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/15/25. The patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.Review of the Visit Note Short Form showed the following dates:-On 1/31/26, the patient found on the floor.-On 2/10/26, the patient had an unwitnessed fall. The patient had multiple bruises and some excoriation on the chest and posterior occipital (back of the head).In addition, the Skin Assessment dated 2/10/26, showed the following skin problems and treatments:-Abrasion/excoriation in the posterior occipital, to cleanse with normal saline, pat dry, apply triple antibiotic ointment to affected area, leave open to air.-Abrasion/excoriation in the right-side upper chest area, to cleanse with normal saline, pat dry, apply triple antibiotic ointment to affected area, leave open to air.-Ecchymosis (bruising) in the right-side chin, to continue monitoring.-Ecchymosis (bruising) in the right lateral wrist, to continue monitoring. Review of the POC/IDG Review dated 2/11/26, showed the following order:-Abrasion/excoriation posterior occipital: to cleanse area with normal saline solution, pat dry, apply triple antibiotic, leave open to air, daily and PRN till healed. The SN will do every Monday and Friday and PRN. The B&C staff will do every Sunday, Tuesday, Wednesday, Thursday, Saturday, and PRN.- Abrasion/excoriation right side upper chest area: to cleanse area with normal saline solution, pat dry, apply triple antibiotic, leave open to air, daily and PRN till healed. The SN will do every Monday and Friday and PRN. The B&C staff will do every Sunday, Tuesday, Wednesday, Thursday, Saturday, and PRN.-Bed rail pads-Floor/fall mat-Extend the full bed rails to cover as much length of the bed.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 2’s fall and abrasion/excoriation.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.3. Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.Review of the Comprehensive Nursing Assessment dated 12/2/25, showed the Braden Risk Chart (evidence-based tool for assessing risk of developing pressure ulcers) for Patient 3 was 12, indicating high risk for pressure injury.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s potential risk for pressure injury.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for three of the three sampled patients (Patients 1, 2, and 3). This failure had the potential of not providing necessary services for these patients. 1.Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed SN visits one time per week and one PRN visit and MSW visits one time per month and one PRN visit.However, there was no documented evidence showing the indication for the SN and MSW PRN visits.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The Administrator and DPCS confirmed the findings.2.Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/15/25. The patient was certified for hospice services during the certification periods from 1/51/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 1/14, 1/28, and 2/11/26, showed SN visits one per week and one PRN visit and MSW visits one time per month and one PRN visit.In addition, the POC/IDG Review dated 2/25, 3/11 and 3/25/26 , showed SN visits two per week plus one PRN visit and MSW visits one per month plus one PRN visit.However, there was no documented evidence showing the indication for the SN and MSW PRN visits.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The Administrator and DPCS confirmed the findings.3.Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/3, 12/17, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed SN visit one per week and one PRN visit.However, there was no documented evidence showing the indication for the SN PRN visit.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. 1. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 1 had a care plan addressing altered bowel elimination with one of the goals to have optimal bowel elimination. However, there was no documented evidence as to what the optimal bowel elimination for the patient was.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/15/25. The patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 2 had a care plan addressing intermittent burning during urination with the goal to verbalize/express understanding of medication/treatment orders and side effects. However, there was no documented evidence what medication/treatment provided and the side effects for the medication.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.3.Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 3 had a care plan addressing potential harm due to alteration in posture with the goal to increase strength/energy for functional activities.However, there was no documented evidence as to what the increase strength/energy for functional activities was.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. The hospice’s P&P titled Interdisciplinary Team Services undated, showed core members include at least the following individuals:i.A Doctor of Medicine or Osteopathyii.A Registered Nurseiii.A Social Workeriv.Chaplain, Pastoral Services and/or other counselors.The IDT meetings will be held on a regular basis (no less often than every 15 days). It is the expectation that all members of the interdisciplinary team will be present. The IDT meeting will include among others evaluating patient/family progress toward achievement of expected outcomes, and revising goals and objectives as needed.1. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified care plan problem included potential for altered bowel elimination, bilateral lower extremity weakness due to bedrest, trouble making needs known related to disease progression, increased risk of aspiration, potential for increasing pain, potential for altered respiratory status and altered sleep patterns. The identified problems were started on 11/21/23.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet the patient’s care needs.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/15/25. he patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified care plan problems included potential for altered cardiac status, potential for altered neurological status, and potential for increased pain requiring increasing dosage of analgesics. The identified problems were started on 1/15/25.In addition, the POC/IDG Review dated 12/31/25, showed patient’s identified care plan problem for decrease in MAC measurement, was 20 cm two weeks ago now at 19 cm decreased by one cm. The identified problem was started on 3/24/25.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet for the patient’s care needs.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.3. Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified problems included deficit in self-care, potential for harm and increased risk related to unsteady gait, potential harm due to alteration in posture, weakness, potential for altered neurological status and potential for altered nutritional status. The problems identified were started on 12/2/25.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet the patient’s care needs.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of three sampled patients (Patient 3). This failure had the potential of not addressing the care needs for this patient. Review of the hospice’s P&P titled Interdisciplinary Team Services, undated, showed the hospice is provided by an interdisciplinary team made up of professionals and volunteers with special training in caring for the terminally ill patient and family. The interdisciplinary team provides support to the client/family throughout the continuum of care. There is communication and coordination and availability of care with all members of the interdisciplinary group.Review of the hospice’s P&P titled Interdisciplinary (IDT) Conferences, undated, showed each staff member will be responsible for discussing appropriate issues/concerns with other disciplines involved in the patient’s care and planning for future care and services, including patient progress, patient education, care/treatment changes, and scheduling needs.Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/3/25, showed an order for referral and treatment for PT times three visits to instruct caregiver on safe transfer/ambulation and range of motion exercises.Review of the PT Evaluation dated 12/31/25, showed the planned treatment and schedule. Frequency would be two to three times a week for one to two weeks. Planned procedures may include: therapeutic exercise, therapeutic activities, neuromuscular re-education and gait. The PT service dates were 1/5, 1/7, and 1/12/26.However, there was no documented evidence the PT coordinated with the IDG regarding the PT evaluation, frequency of visits, and progress of the patient. On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.”

“Upon observation, there was no evidence the hospice that is using contract personnel for core services met the following exception: The hospice may use contracted personnel, if necessary, to supplement hospice personnel in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice personnel to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice’s service area. Patient #2, No evidence of documentation that wound care provided by Wound Pro’s is not related to terminal diagnosis. No evidence document on the CTI or in IDG meeting notes. Patient had multiple wounds that required debridement with the exception of Left Midline plantar stage 2 wound. No evidence this wound required debridement, Wound Pro’s provided care to this wound when the hospice nurse is capable to manage this wound.”

“Upon patient record review, 1 of 5 (Patient #2) 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, On 8/21/25 order for Sinemet 10/100mg 1 tablet every 6 hours. On 9/16/25 order for Sinemet 25/100mg. No evidence documented if these medications are to be taken together or if the order on 8/21 should have been discontinued.”

“Upon client record review, 2 of 5 (Patient #1,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 8/22/25 SN frequency 1x/week and 1 PRN, 8/24/25 3x/week 1 PRN, 9/1/25 SN 2x/week 1 PRN, 9/7/25 SN 2x/week 1 PRN, 9/12/25 SN 1x/week. SN visits completed 8/30, 9/2, 9/4, 9/9, 9/16/2025. Order written on Thurs 9/9 for SN 2x/week, only has 1 visit that week. MSW documented as declined, will add an order if PRN need arises. MSW made an initial visit on 8/21/25 and PRN visit on 8/28/25. No evidence of orders for these visits. Patient #3, No evidence of order for SN frequency on plan of care. IDG has SN order frequency without any MD signatures on IDG notes. No evidence of a frequency order for SN services. SN visits were made on 9/4, 9/11, 9/18/2025.”

“Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #2, No evidence of coordination of care with wound pro’s documentation in IDG meeting. IDG meeting today, care plan for skin integrity updated with wound care order from 9/4/25 from wound pro’s when there are new orders from wound pro’s documented on 9/18/25. No evidence of new wound order were updated in orders or care plan. RN made visit on Thursday 9/18/25, when order states wound pro’s will visit every Thursday. No evidence of coordination when RN makes visit on same day as wound pro’s.”

“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 as evidenced by ensuring that a qualified Administrator is employed-Personnel # 1, Job descriptions states Administrator will have bachelor in business or Healthcare degree. Administrator has High school education with Administrator certificate. In addition, the lack of oversight for ensuring core services, such as nursing, are being performed, staff practice according to acceptable standards and scope, and ensuring agency is following CMS 418.56 Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient #5, Upon record review LVN made death visit arrived at 12:50pm. Narrative note documents Upon arrival, family at bedside. No heart rate, no respirations, and no response to painful stimulus. Assessment completed, time of death 1254. Dr Moran notified at1258. LVN did not work within her scope of practice as LVN does not meet criteria in California Subchapter 3. Health Care Operations Article 4. Nursing Care section 3999.327. Registered Nurse Pronouncement of Death.”

“Upon patient record review, 2 of 5 (Patient #2,3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #2, 3,No evidence of clinical information in CTI narrative. Narrative documents, see documentation in patient chart.”

“Upon patient record review 3 of 14 (Patient #1,5,6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 1: There was no psychosocial assessment completed, no evidence the SN completed in the SOC comprehensive assessment. Patient 5: There was no SC assessment performed within the first 5 days. Patient refused, and SN did not complete the assessment in the comprehensive assessment. Patient 6: There was no SC assessment performed within 5 days of SOC. The RN did not complete during SOC comprehensive assessment.”

“Upon patient record review, 6 of 14 (Patient #2,3,4,5,6,9) 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: Patient 2: The medication profile 7/15/25 contains an order for Lidocaine patch with no site to apply patch. Corrected on site order updated. Patient 3: The current medication profile contains an order for Optimag Neuro powder 1 scoop oral daily with no diluent. Corrected on site order updated. Patient 4: The medication profile contains an order for Topical ointment 0.44% apply 1 inch topically; Frequency: as needed if no bm on second day; Indication: redness on buttocks area. Order frequency is not appropriate for medication ordered. Corrected on site order updated. Patient 5: The medication profile has orders for 7/31/25 Fentanyl 50mcg/hr every 72 hours, on 7/26/25 Fentanyl 50mcg/hr every 72 hours and on 7/15/25 Fentanyl 50mcg/hr every 72 hours, on 7/10/25 Fentanyl 25mcg patch apply every 72 hours. It is unclear what dose of Fentanyl patch the patient is taking. All of the Fentanyl orders remain active on the medication profile. Corrected on site, extra orders discontinued. Patient 6: Medication profile listed a 12/10/24 Medication: Mupirocin 2% Topical cream; Frequency: apply thin layer to affected areas three times daily for 7 days. No indication of where to apply. The SN did not update medication list to remove once discontinued. Corrected on site, medication discontinued. Patient 9: Medication profile listed Robitussin 15mg cough gels with no indication of frequency, noted as: “Q^hrs PRN”.”

“Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients 13 and 14: The medical record did not have an initial bereavement assessment completed within the first 5 days on service.”

“Upon patient record review, 1 of 14 (Patient #5) 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 5: The SN documented on 7/7/25 patient pain “0, pt refused to state pain”. The SN also documented “Nurse explained she was there to place his fentanyl patch which had been increased due to his pain”. There is no evidence the SN performed a non verbal or pain AD assessment on the patient to assess pain while increasing a fentanyl patch. There is no documentation regarding which dose of Fentanyl patch was applied. The SN documented on 6/25/25 the Safety Risk Assessment & Fall risk assessment both checked as yes however corresponding assessments are not completed.”

“Upon patient record review, 5 of 14 (Patient #3,4,7,8,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: Orders on 5/10/25 indicate barrier cream to coccyx daily and prn diaper changes. No care plan with goals and interventions for skin integrity initiated. Corrected on site, care plan added. Patient 4: Fall risk was assessed on admission with a score of 22. No goals and interventions for fall risk. Orders for topical barriers to prevent skin breakdown; there was no skin integrity care plan with goals and interventions initiated. Pt on routine ASA with no risk for bleeding care plan with goals and interventions. Patient also has pruritis with associated daily use topical cream; no care plan initiated for related pruritis. Corrected on site, all care plans added Patient 7: Area to right buttock with orders for excoriation, no skin integrity care plan initiated with goals and interventions. Corrected on site, care plan added. Patient 8: Fall risk score dated 6/24/25, 12 (high risk), mobility care plan notes “ambulatory with fall risk”. No care plan for fall risk with interventions and goals initiated. Corrected on site, care plan added. Patient 10: Patient has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, care plan added.”

“Upon patient record review, 6 of 14 (Patient #2,3,4,5,6,9) 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: The POC 7/15/25 contains an order for Lidocaine patch with no site to apply patch. The current POC has an order from 7/22/24 to cleanse mouth with colloidal silver and apply rolled gauze with no frequency. Corrected on site, orders updated. Patient 3: The current POC contains an order for Optimag Neuro powder 1 scoop oral daily with no diluent. Corrected on site. Patient 4: The current POC contains an order for Topical ointment 0.44% apply 1 inch topically; Frequency: as needed if no bm on second day; Indication Orders: redness on buttocks area. Order frequency is not appropriate for medication ordered. Corrected on site. Patient 5: The POC has orders for 7/31/25 Fentanyl 50mcg/hr every 72 hours, on 7/26/25 Fentanyl 50mcg/hr every 72 hours and on 7/15/25 Fentanyl 50mcg/hr every 72 hours, on 7/10/25 Fentanyl 25mcg patch apply every 72 hours. It is unclear what dose of Fentanyl patch the patient is taking. All of the Fentanyl orders remain active on the POC. Corrected on site, orders discontinued for extra Fentanyl. Patient 6: Order dated 12/10/24 Medication: Mupirocin 2% Topical cream; Frequency: apply thin layer to affected areas three times daily for 7 days. No indication of where to apply. The SN did not update the POC to remove once discontinued. Corrected on site, medication discontinued. In addition, the POC 5/20/25 contains an order to insert and irrigate a foley catheter but does not state who will perform the insertion and irrigations. The POC contains orders for a dressing change to a Stage II Pressure ulcer on coccyx, there is no indication of who will complete the dressing changes. Corrected on site foley order has who is to perform and the pressure ulcer dressing discontinued. Patient 9: Order for Robitussin 15mg cough gels with no indication of frequency, noted as: “Q^hrs PRN”. Corrected on site, order updated.”

“Upon patient record review, 3 of 14 (Patient #4,6,9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 4: Fall occurrence noted 4/1/2025 at 4:15pm unwitnessed in patients room at B&C while transferring, no injury noted. Narrative notes patient found sitting on floor in no acute distress. Patient states she hit her head on the dresser, lost her balance standing up from wheelchair. Subsequent recertification assessment dated 4/7/2025 and visit dated 6/30/25 indicate patient is a high risk with a risk score of 15. No fall care plan initiated. Patient 6: Patient currently receiving antibiotics and topical cream related to infection/MRSA. On 10/24/2024, UA & CNS indicates MRSA; 12/02/2024 UA obtained with culture indicates MRSA. No infection plan of care initiated. Corrected on site, care plan added. Patient 9: Current care plan for skin integrity has not been updated with current orders dated 6/6/2025. Corrected on site, new order obtained. POC updated.”

“Upon patient record review, 5 of 14 (Patient #2,4,5,6,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: There is an order for Massage therapy on POC for 7/1/25 for a 1 time visit. There is no evidence the visit was made. There was no evidence of refusal of massage therapy. The current POC contains an order to cleanse the mouth with colloidal silver, apply rolled gauze insert to side of mouth to protect lips from teeth clenching. The SN documented on 7/24/25 and 7/30/25 “Applied rolled gauze soaked with colloidal silver to protect lips from teeth clenching.” The SN did not follow the order to cleanse the mouth. Patient 4: RN Routine visit noted 3/31/2025; PRN on call for fall 4/1/2025; PRN on call for Burning with urination/ with new orders 4/7/2025; RN routine visit again noted 4/14/2025. Visit frequency is for weekly and 1 prn. Routine visit missed / assessment not completed for the week of 4/7/2025. Patient 5: The POC 6/25/25 order for SN is for 2 times per week with 1 PRN. There is evidence SN made visits on 6/25/25 for SOC, a PRN on 6/25/25 for pain control, 6/27/25 routine and 6/28/25 routine. There is no order for an increase in visits. The SN documented on 6/25/25 “12.5mcg patch applied to Lt ACW”. There is no order for a Fentanyl 12.5 patch on the POC. In addition, the POC contains an order for SN twice a week and 1 PRN per week. SN is visiting patient three times per week routinely due to Fentanyl patch needing changed. Pt was seen twice on 7/1/25 and then on 7/3/25. The SN made visits on 7/6,7/8,7/10. The SN made visits 7/16, 7/18,7/19. There is evidence the SN is seeing the patient 3 times per week routinely to change Fentanyl patch though no evidence the SN updated the POC to SN 3 times per week. Corrected on site, new order obtained and POC updated. Patient 6: The current POC orders are for SN once a week. The SN made two visits the week of 7/20-7/26. There was no order to increase the visits. Patient 9: SC frequency has been 2x/month and 1 prn. 1 visit made 05/29/25; 1 visit made 6/25/25; no visits made in July.”

“Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,7,10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1:The aide POC 7/24/25 contains an order for turn and reposition, transfer, change linens with no frequency. Corrected on site, frequency added. Patient 2:The aide POC 7/9/25 contains an order for “chair to bed”, record BM, feeding assistance, change linens all with no frequencies. Corrected on site, frequency added. Patient 3:The aide POC 7/29/25 contains orders to turn and reposition, transfer, street clothes, change linens all with no frequency. The diet is ordered as “other”.Corrected on site, frequency and diet added. Patient 4: The aide POC contains order to turn and reposition, chair to bed, record BM, pajamas/gown, change patient linens all with no frequencies. Corrected on site, frequency added. Patient 5: The aide POC 7/21/25 contains orders for turn and reposition, record bowel movements, and change patient linens without frequencies. Corrected on site, frequency added. Patient 6: The aide POC contains orders to turn and reposition, empty collection bag with no frequency. There is a directive to dress patient every visit but does not indicate street clothes or pajamas to dress the patient in. Pt is confused. Corrected on site, care plan updated. Patient 7: The aide POC documentation listed a frequency of “NA” for change patient linens. Corrected on site, frequency added. Patient 10: The aide POC documentation listed a frequency of “NA” for turn and reposition. Encourage fluids as tolerated unless contraindicated. Corrected on site, frequency and diet order added.”

“Upon patient record review, 4 of 14 (Patient #1,4,5,6) 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: Advance Directive section both check boxes indicating the patient has an Advance Directive and does not have an Advance Directive are checked. Patient 4: The SN documented S-I-L in narrative on 7/14/25. This is not an approved abbreviation. Patient 5: The SN made an aide supervisory visit on 6/27/25, there is evidence the aide did not start seeing the patient until 6/30/25. The SN documented on 6/28/25 “Fentanyl patch change place in left upper chest”. There is no evidence of the dose of Fentanyl patch applied. SN documented on 7/1/25 “ROLC” This is not an approved abbreviation. Patient 6: Advance Directive section both check boxes indicating the patient has an Advance Directive and does not have an Advance Directive are checked. The SN documented F/C on 6/30/25 this is not an approved abbreviation. The SN documented 7/21/25 “New 18F catheter inserted, Pt tolerate well”. There is no evidence of balloon size or that sterile technique was used.”