Gibraltar Hospice, Inc.

“Observed in Record Review. In 5 out of 5 records reviewed, the organization failed to ensure that the written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in record review for RRNHV#1, the patient had an identified integumentary issue of Itching, with the associated goal of, Prevent potential skin problems for comfort. In record review for RRNHV#2, the patient had identified problem of Spiritual distress, with an associated goal of, Pt/cg to receive spiritual support during hospice care. In record review for RRNHV#3, the patient had an identified issue of, Potential for altered bladder elimination r/t; incontinent to bladder, with an associated goal of, Patient/family/pcg will verbalize having urinary elimination needs met at an acceptable level. In record review for RRNHV#4, the patient had an identified issue of, Cognitive impairment, with an associated goal of, Patient needs will be met on a day-to-day basis as communicated. In record review for RRCR#1, the patient had an identified issue of, Diabetes, with an associated goal of, Patient blood sugar management for pt comfort will continue to be monitored for next IDT. All goals developed by the organization lacked specificity and were not individualized based on the needs of the patients. This was reviewed, discussed, and validated with the DPCS and administrator designee.”

“Observed in Record Review. In 1 out of 5 records reviewed, the organization failed to provide the patient with care, treatment, or services according to the patient’s individualized plan of care. For example, in record review for RRNHV#1, the plan of care included a visit frequency for a Registered Nurse (RN) one time per week; however, there was a period of three weeks prior to the survey date where the RN had not visited the patient. There was no documentation to explain why the RN had not seen the patient as ordered. This was reviewed, discussed, and validated with the DPCS and administrator designee.”

“Observed in Record Review. In 1 out of 1 closed records reviewed, the organization failed to maintain complete and accurate patient records. For example, in record review for RRDC#1, it was documented that the patient had been discharged for extended prognosis. The organization further documented in the discharge plan and discharge summary, that the patient was being discharged after, no decline for the past several weeks. However, in the documented interdisciplinary group (IDG) note that occurred eight days prior to the discharge, it was documented that the patient continued to remain eligible for hospice services and satisfied criteria for a prognosis of less than six months. There was no explanation for the discrepancy. This was reviewed, discussed, and validated with the DPCS and administrator designee.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not conduct a patient specific reassessment that included the patients’ needs for management for all areas of hospice care related to the palliation and management of the terminal illness and related conditions. For example, observed during RRHV#1 and during RRHV#3 the skilled nurse did not conduct a full skin assessment on the patients who were bedbound, had increased weakness, limited mobility, and were incontinent. This was validated with the Administrator Designee and Director of Patient Clinical Services following the home visits conducted.”

“Observed in Record Review. In 3 of 10 patient records reviewed, the organization did not ensure that the hospice interdisciplinary group (IDG) reviewed, revised, and documented the individualized plan no less frequently than every 15 calendar days. Identified during the record review for RRHV#2, there was no documentation to support that the hospice IDG reviewed the plan of care during the 20 days following the patient’s admission date/initial IDG date. Identified during the record review for RRNHV#3, there was no documentation to support that the hospice IDG reviewed the plan of care during October 2025, December 2025 and January 2026. Identified during the record review for RRNHV#5 there was no evidence to support that the hospice IDG reviewed the plan of care during October 2025, December 2025 and January 2026. This was validated with the Administrator Designee following the record review session.”

“Observed in Tracer Activities. The governing body/leadership did not ensure that the following conditions of participation were met as determined through observations, documentation, and staff interviews: 418.54 and 418.56. These were reviewed and discussed with the Administrator Designee. Observed in Patient Home. In 2 of 2 staff interviews, it was identified that the organization does not provide clinical staff with resources needed to maintain safe, quality care, treatment or services. For example during the three home visits conducted with two different clinical staff, the Surveyor noted the different types of equipment and supplies were being used by each. The clinicians validated that the Personal Protective Equipment, disinfecting supplies, barriers, and reusable medical equipment was purchased by themselves and were not provided by the organization. This was verified with the Administrator Designee following the home visits.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not conduct an effective assessment of the patient’s medication in accordance with organizational policy no. 3-002.2, 5) During subsequent hospice visits, the medication profile will be used . . .A)to evaluate the use of drugs in the home setting . . . Observed in RRHV#3, the skilled nurse did not utilize the medication profile to evaluate the patient’s use and understanding of the medications, instead just picking up and reading each medication containers. This was validated with the Administrator Designee and the Director of Patient Clinical Services following the home visit.”

“Observed in Record Review. In 10 of 10 patient records reviewed, the goals developed did not reflect patient and family goals based on the problems identified in the assessments. For example, in RRHV#1, the psychosocial assessment documented the problem needs funeral arrangements, with a corresponding goal, MSW will facilitate resolution. In RRHV#2, the psychosocial problems documented were Patient is sad, and Patient gets frustrated with corresponding goals Social Worker will assist in providing resources, and Social Worker provided complement added resources and support. Additionally in RRHV#2, the Spiritual Care Coordinator documented the following assessed problem, spiritual distress with the corresponding goal, pt/cg to receive spiritual support during hospice care. In RRHV#3 the psychosocial problems identified included, Pt’s appetite has declined, and Pt has more episodes of forgetfulness, with the corresponding goals, Social Worker will establish trusting relationship, and Social Worker will provide emotional support. In RRNHV#1, the psychosocial identified problem was Pt continues to struggle with anxiety, with a documented goal of Social Worker provided counseling. In RRNHV#2, the psychosocial problem identified was Pt lacks coping skills, with a corresponding goal of Social Worker will assist Pt in complementing added resources. In RRNHV#3, the psychosocial problem identified was Pt without funeral arrangements with a corresponding goal of Social Worker will educate Pt on the importance of mortuary arrangements. In RRNHV#4 the psychosocial problems identified included agitation, and Pt felt sadness due to illness progression, with corresponding goals of Social Worker will assist in providing resources and support as needed, and Social Worker will provide support. In RRNHV#5 the psychosocial problem identified was Pt is sad due to not being able to take long walks, with a corresponding goal of SW will assist Pt to share less stress and or acceptance. In RRNHV#6 the psychosocial problem identified was Pt is sad due to pression of illness, with a corresponding goal of SW will assist in complementary added resources and support as needed. In RRNHV#7 the Psychosocial problem identified was Pt continues to be confused with episodes of forgetfulness, with a corresponding goal of SW educated Pt daughter on the importance of having all community resources in place . . . This was validated with the Director of Patient Clinical Services following the record review session.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not include all services needed for the management of the terminal illness and related conditions. For example, identified during the record review for RRHV#1, the patient was assessed to have a high risk for falls, yet there was no care plan developed to address this problem. Identified during the record review for RRHV#2, the patient was assessed to be at a high risk for aspiration, being nutritionally compromised, have impaired skin integrity due to being paralyzed, incontinent and suffering from basal cell carcinoma, and have ongoing pain issues, yet there were no care plans developed to address these problems.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the individualized plan of care. Identified during the record review for RRHV#2, there was no documentation that the ordered weekly Licensed Vocational Nurse (LVN) visit was completed one week prior to the survey date. Identified during the record review for RRNHV#5, there was no documentation to support that two LVN visits were conducted during the sixth month prior to the survey month. This was validated with the Director of Patient Clinical Services following the record review session.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not ensure that accepted standards of practice were met to prevent the transmission of infections. Observed in RRHV#1 the Skilled Nurse did not perform hand hygiene following the assessment and palpation of the colostomy site, instead doffing gloves and immediately returning to the inside of the clinician supply bag. Additionally, the Skilled Nurse did not clean the equipment used to assess patient RRHV#1, before returning the equipment to a gallon size zip lock bag and placing it into the clean area of the clinician supply bag. In the following home visit conducted, the same Skilled nurse used the same reusable medical equipment to assess RRHV#3 and again did not clean the reusable medical equipment before returning it to the plastic zip lock bag located in the clinical supply bag. This was validated with the Administrator Designee and the Director of Patient Clinical Services following the home visits conducted.”

“Observed in Medication Management Tracer. In 2 of 3 patient records reviewed, the organization did not ensure that the patient’s record contained information that reflected the patients’ care, treatment, or services. Observed during the home visit for RRHV#2, there were medications in the home that were not listed in the medical record including: Morphine Sulfate 10mg/0.5ml prefilled syringes, Ativan 0.5mg/0.25ml prefilled syringes, over the counter stool softener DS 100mg, and Tylenol 325mg tablets. Observed during RRHV#3, the patient did not have supplemental oxygen, yet the medical record included oxygen in the Plan of Care. Additionally the patient’s hospital bed had full side rails not the half rails as documented in the medical record. This was validated with the Administrator Designee and the Director of Patient Clinical Services.”

“Observed in Patient Home. In 1 of 3 home visits conducted, where the patient had a hospital bed, there was no evidence that the family caregiver received instructions in the safe use of durable medical equipment. Observed during the home visit conducted for RRHV#3, the patient was in a hospital bed with full side rails. Upon reviewing the record there was no documentation to support that the family caregiver was informed of risks associated with full bed rails. This was validated with the Administrator Designee and Director of Patient Clinical Services following the home visit.”