San Gabriel Hospice

“Upon patient record review, 6 of 14 (Patient #4,5,7,8,9,10) 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 4: Current Medication list dated 09/16/25 contains orders for Norco 5mg-325mg 1 tab every 6 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, medication record updated. Patient 5: Current Medication list dated 09/16/25 contains orders for Norco 10mg-325mg 1 tab every 8 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, medication record updated. Patient 7: Current Medication list dated 9/16/25 contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, medication record updated. Patient 8: Current Medication list dated 9/16/25 contains order for Hydrocortisone 1% topical Cream topically to affected area twice daily as needed for itching. Order does not indicate location of application. Corrected on site, medication record updated. Patient 9: Current Medication list dated 9/16/25 contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, medication record updated. Patient 10: Current Medication list dated 9/16/25 contains order for Miconazole Nitrate 2% 1 application topically to affected area twice a day for indication of rashes. Order does not indicate location of application. Corrected on site, medication record updated.”

“Upon patient record review, 5 of 14 (Patient #1,3,4,5,6) 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 1: The POC dated 09/16/25 has a medication order for ASA (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Patient 3: The current POC dated 09/16/25 has a medication order for ASA (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 4: The POC dated 09/16/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated Patient 5: The current POC dated 09/16/25 has a medication order for ASA daily (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated Patient 6: The current POC dated 09/16/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated”

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 4: Record indicates patient has been seen monthly by SW since admission 12/31/24, visit frequency order remains prn monthly with no scope or frequency on the POC. Corrected on site, POC updated.”

“Upon patient record review, 6 of 14 (Patient #4,5,7,8,9,10) 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 4: The POC contains orders for Norco 5mg-325mg 1 tab every 6 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, POC updated. Patient 5: The POC contains orders for Norco 10mg-325mg 1 tab every 8 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, POC updated. Patient 7: The POC contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 8: The POC contains order for Hydrocortisone 1% topical Cream topically to affected area twice daily as needed for itching. Order does not indicate who will apply or location of application. Corrected on site, POC updated. Patient 9: The POC contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 10: The POC contains order for Miconazole Nitrate 2% 1 application topically to affected area twice a day for indication of rashes. Order does not indicate who will apply or location of application. Corrected on site, POC updated.”

“Upon patient record review, 3 of 14 (Patient #1,7,8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 1: Current Aide POC dated 8/8/25 does not include frequency for turn and reposition, record bowel movements or feeding assistance. Corrected on site, POC updated. Patient 7: Current POC dated 9/16/25 indicates a walker is required for ambulation. Current Aide POC dated 5/21/25 does not list walker as a required ambulatory device; lists the patient as bedbound and non ambulatory. Corrected on site, POC updated. Patient 8: Current Aide POC does not indicate frequencies for dressing,oral care or nail care. Shower chair is marked on Aide POC however shower, tub bath or bed bath are not indicated. Corrected on site, POC updated.”