True Care Hospice Southern California, Inc.

“Upon patient record review, 2 of 14 (Patient #1,#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 1: Facility medication profile contains Morphine 10mg/5ml administer 0.5ml Q3H PRN, however, the hospice medication profile contains Morphine 20mg/ml administer 0.5ml Q3H PRN. Patient 2: Medication profile contains Polyethylene Glycol powder with no instructions for diluent.”

“Upon patient record review, 3 of 14 (Patient #1,#6,#8) 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: Patient was identified as an aspiration risk upon admission, however, there is no evidence of problems, goals and interventions for aspiration precautions. Patient has been taking an anticoagulant since admission with no evidence of a care plan for risk for bleeding. Patient 6: Patient has been taking an anticoagulant since admission with no evidence of a care plan for bleeding risk. Patient 8: Patient has been taking an anticoagulant since admission with no evidence of a care plan for risk for bleeding. Also, on admission a care plan was opened for suspected blood in the stool and sample obtained. Results were negative, however, care plan remains open.”

“Upon patient record review, 4 of 14 (Patient #1,#5,#6,#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 equipment and supply needs. Patient 1: In the home, patient has an e-tank, bedside commode, and shower chair with no evidence of orders in the plan of care. In addition, DME order on 12/15/25 for hospital bed with 1/2 rails. On 2/18/26 another DME order was obtained for full rails due to fall risk, however, home visit confirmed patient still has 1/2 rails the plan of care for DME was not updated. Patient 5: On admission, patient identified as using a walker, and in the home, patient has a bedside commode. However, there was no evidence of orders in the plan of care for DME. Patient 6: On admission, patient identified as using a walker, and in the home, patient has an e-tank, portable oxygen concentrator, and wheelchair. However, there was no evidence of orders for the DME. Patient 10: Patient identified on admission as using a walker, however, there was no evidence of orders in the plan of care.”

“Upon patient record review, 2 of 14 (Patient #2,#6) 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 2: Care Plan opened on 2/9/26 for vaginal discharge related to antibiotic therapy. However, the problem was resolved but care plan remained open. Patient 6: 3 care plans are open for potential for altered neuro status; increased agitation. The care plan on 5/26/25 with intervention of Seroquel 25mg BID, 8/26/25 with intervention of Seroquel 50mg BID and 12/19/25 with intervention of Seroquel 75mg BID which is current. The other 2 care plans should have been discontinued.”

“Upon patient record review, 4 of 14 (Patient #1,#2,#6,#10) 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 1,6: Patient taking an anticoagulant, however no evidence of bleeding precautions on the aide care plan. Patient 2: Patient taking an anticoagulant, however no evidence of bleeding precautions on the aide care plan. Also, there was no frequency instructions for task to empty foley collection bag. Patient 10: Admission POC contains order for wheelchair and bedrails, however, there was no tasks or instructions in the aide care plan. Patient also identified on admission as a standby assist when using a walker, however, no instruction provided for standby assist on the aide care plan.”

“Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 1: Supervisory visit was made on 1/25/26 and not another supervisory visit until 2/16/26. On 2/6/26, RN documented supervision of LVN and Aide, but only the LVN supervision section was completed.”