Cabrillo Hospice

“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 one of three sampled patients (Patient 1). This failure had the potential for not providing appropriate, consistent, and quality care to the patient. Finding: Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 4/2020 showed the patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient. The Plan of Care will be updated in the EMR system and reviewed with the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include:A. Pharmacotherapeutic effectiveness of symptom management outcomesB. An increase or decrease in symptoms or acuity1. Nutritional status2. Pain management3. Condition of skin/presence/status of pressure ulcersC. Increases or decreases in frequency of visits by team members and reason for the change1. Missed visits by aides and staff will be explained and adjustment to the POC will be made if appropriateD. Changes in the location of careE. Psychosocial and other consultations/conferences with patient and family/caregiverF. Changes that may contribute to risk for pathological griefG. Ongoing spiritual supportH. Plan for changes in treatments or procedures, Review of the hospice’s P&P titled Clinical/Service Data Collection dated 4/2020 showed documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary. Review of Patient 1’s clinical record was initiated on 8/19/26. The clinical record showed the SOC was 6/2/26. The patient was certified for hospice services during the certification period from 6/2/26 to 8/30/26. Review of the Wound Care Consult date of service 6/22, 6/29, and 7/20/26, showed the following: -Under the section of Chief Complaint, wound care was consulted for managing wound(s).-Under the section of Wound Assessment, the patient was with suspected infection, Stage 4 pressure injury on sacrococcyx of the sacral region-Under the Treatment Plan section, to cleanse with 0.125% Quarter Strength Dakin’s solution (antiseptic), pat dry, fill loosely with 500 mg crushed Flagyl (antibiotic), apply Santy (ltopical debriding agent) and mupirocin 2% (topical antibiotic) directly to wound bed, apply Alginate Ca (wound dressing), cover with a bordered foam dressing, and secure with retention tape; and to change dressing every three days and PRN for loss of integrity/Soiling.-Under the section of Recommendations, for aggressive offloading, recommend frequent diaper checks and changes, heel floaters, heel protectors, low air loss mattress, offload heels on pillows, turning and repositioning per facility protocol. Additional recommendations included turn and reposition patient per facility/agency protocol, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle-free, remove all products with fragrance, including body washes and lotions, and recommendation for patient should use chemical-free, fragrance-free disposable washcloths. Review of the IDG meeting notes dated 6/26, 7/10, and 7/24/26, showed the patient was with sacrococcyx wound. The interventions Activities section showed to cleanse with quarter strength Dakin’s solution, pat dry, apply santyl mupirocin 2% directly to wound bed, and dress with alginate, cover with a border foam dressing, and secure with retention tape. *However, there was no documented evidence the IDG members revised the POC related to the wound care consult treatment plan and recommendation on the sacrococcyx wound. On 8/24/26 at 0953 hours, an interview and record review was conducted with the DPCS and Administrator. The DPCS and Administrator were informed and acknowledged findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services related to missed visit for one of three sampled patients (Patient 2). This failure had the potential of not addressing the care needs for this patient.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities dated April 2020 showed the interdisciplinary group responsibilities include but not limited to:-Provision and/or supervision and coordination of hospice care/services-Establishment and implementation of policies and procedures governing the day-to-day provision of hospice care and services. Review of the hospice’s P&P titled Missed Visits revised 4/2020 showed missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. MIssed visits will be documented in the clinical record. Procedure included: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.2. If a visit is missed and not rescheduled the clinician will:A. Notify the IDG physician and clinical supervisor of the missed visit and reason for missed visitB. Document in the patient’s clinical record the following information:1. Patient name2. Date and type of visit that was missed3. Reason for the missed visit4. Description of any unmet needs and how the patient’s needs were met5. Any other follow-up needed6. Other person(s) that were notified of the missed visit7. Signature of staff member reporting the information3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 4. The clinical supervisor will track the number and reasons for missed visits to assesspatterns and to assure that the plans of care contain the correct number of planned visits. Review of Patient 2’s clinical record was initiated 8/19/26. The clinical record showed the SOC was 5/21/24. The patient was certified for hospice services during the certification periods from 5/21/2024 to 8/18/2024, 8/19/24 to 11/16/24, 11/17/24 to 1/15/25, 1/16/25 to 3/16/25, 3/17/25 to 5/15/25, 5/16/25 to 7/14/25, 7/15/25 to 9/12/25, 9/13/25 to 11/11/2025, 11/12/25 to 1/10/26, 1/11/26 to 3/11/2026, 3/12/26 to 5/10/26, 5/11/26 to 7/9/26, and 7/10/26 to 9/7/26. Review of the POC dated 6/2/26, showed hospice aide frequency of two times a week. Review of the HA visits for the week of 6/7/26 to 6/13/26, showed only one HA visit dated 6/9/25, was completed, instead of two times a week. Review of the Missed Visit Form (Aide Care Visit) dated 6/11/26, showed the reason for missed visit was cancellation of care. The RN Case Manager was notified of missed visit and the physician and supervisor was informed. *However, there was no documented evidence it was rescheduled for the same week as per the agency’s P&P. The IDG failed to maintain the responsibility for directing, coordinating, and supervising the services provided related to the missed visit. On 8/24/26 at 0925 hours, an interview was conducted with the DPCS and Administrator. The Administrator was informed and acknowledged the finding.”

“Upon patient record review, 7 of 19 (Patient #1,#2,#3,#4,#5,#9,#11) 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: During medication reconciliation, discrepancies were identified between the facility and hospice medication profiles. The hospice medication profile included Mylanta, guaifenesin, and scheduled lorazepam, none of which were listed on the facility medication profile. Oxcarbazepine was listed on the facility medication profile but was not included on the hospice medication profile. Patient 2: During medication reconciliation, discrepancies were identified between the facility and hospice medication profiles. Trazodone was listed only on the hospice medication profile, while tramadol was listed only on the facility medication profile. Patient 3: During medication reconciliation, discrepancies were identified between the facility and hospice medication profiles. The hospice medication profile included hydrocodone-acetaminophen and lorazepam, which were not listed on the facility medication profile. Rytary and Ocusoft eyelid scrub was listed on the facility medication profile but was not included on the hospice medication profile. Patient 4: The medication profile contained Tretinoin cream with instructions to apply to affected area for rash; however, location was not specified. Patient 5: The medication profile contained triple antibiotic ointment with instructions to apply to affected area; however, location was not specified. Patient 9: The medication profile contained polyethylene glycol with no instructions to mix with a diluent. Patient 11: The medication profile contained MiraLAX with no instructions to mix with a diluent.”

“Upon patient record review, 6 of 19 (Patient #4,#6,#7,#8,#12,#14) 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 4,14: The patient is a risk for bleeding due to use of aspirin since admission. There was no evidence of problems, interventions and goals related to the issue included in the plan of care. Patient 6: The patient is a risk for bleeding due to use of Xarelto and Clopidogrel since admission. There was no evidence of problems, interventions and goals related to the issue included in the plan of care. Patient 7,12: The patient is a risk for bleeding due to use of Apixaban since admission. There was no evidence of problems, interventions and goals related to the issue included in the plan of care. Patient 8: The patient is a risk for bleeding due to use of Eliquis since admission. There was no evidence of problems, interventions and goals related to the issue included in the plan of care.”

“Upon patient record review, 7 of 19 (Patient #1,#2,#3,#4,#5,#9,#11) 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 1: During medication reconciliation, discrepancies were identified between the facility and hospice medication orders. The hospice medical record contained orders for Mylanta, guaifenesin, and scheduled lorazepam, none of which were listed on the facility medical record. Facility medical record contained order for Oxcarbazepine but was not included in the hospice medical record. Also, the medical record contained an order for barrier cream to be applied to wound to buttock with no specification to which buttock. Patient 2: During medication reconciliation, discrepancies were identified between the facility and hospice medication orders. The hospice medical record contained order Trazodone, while order for tramadol was in the facility medical record. Patient 3: During medication reconciliation, discrepancies were identified between the facility and hospice medication orders. The hospice medical record contained orders for hydrocodone-acetaminophen and lorazepam, which were not contained in the facility medical record. Rytary and Ocusoft eyelid scrub was ordered in the facility medical record but was not included in the hospice medical record. Patient 4: The medical record contained order for Tretinoin cream with instructions to apply to affected area for rash; however, location was not specified. Patient 5: The medical record contained order for triple antibiotic ointment with instructions to apply to affected area; however, location was not specified. Patient 9: The medical record contained order for polyethylene glycol with no instructions to mix with a diluent. Patient 11: The medical record contained order for MiraLAX with no instructions to mix with a diluent.”

“Upon patient record review, 8 of 19 (Patient #1,#2,#3,#4,#7,#12,#13,#14) 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: During home visit, patient identified as having a Hoyer lift, wheelchair and 1/2 rails; however, there was no evidence of orders for the DME included in the plan of care. Patient 2: During home visit, patient identified as having a 1/2 rails; however, there was no evidence of orders for the DME included in the plan of care. Patient 3: During home visit, patient identified as having a roller walker, raised toilet seat, shower chair, halo bed rail and fall mats; however, there was no evidence of orders for the DME included in the plan of care. Patient 4: During home visit, patient identified as having a shower chair, fall mats, APP overlay, and raised toilet seat; however, there was no evidence of orders for the DME included in the plan of care. Patient 7: The medical record contains orders for 2 medications to be administered via nebulizer; however, there was no evidence of a nebulizer included in the plan of care order. Patient 12: The medical record contains an order for albuterol to be administered via nebulizer; however, there was no evidence of a nebulizer included in the plan of care order. Patient 13: The medical record contains documentation identifying patient use of a Hoyer lift; however, there was no evidence of orders included in the plan of care. Patient 14: The medical record contains documentation identifying patient use of a feeding pump; however, there was no evidence of orders included in the plan of care.”

“Upon patient record review, 9 of 19 (Patient #1,#2,#4,#8,#9,#11,#12,#13,#14) 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: The aide care plan contained no instructions for use of Hoyer lift or patient’s use of wheelchair. Also, there was no instructions for risk for dysphagia, as documented since admission. Patient 2: The aide care plan contained no instructions for patient’s use of wheelchair or walker. Patient 4: The aide care plan contained no instructions for patient’s use of wheelchair. Also, patient taking an anticoagulant; however, there was no evidence of instructions for bleeding precautions on the aide care plan. Patient 8: Aide care plan contained tasks with frequencies of “as needed” and “as requested”. However, patient unable to make decisions due to documented cognitive impairment. Also, patient taking an anticoagulant; however, there was no evidence of instructions for bleeding precautions on the aide care plan. Patient 9: The aide care plan contained no instructions for use of Hoyer lift. Patient 11: The aide care plan contained no instructions for use of Hoyer lift. Also, the aide care plan contained instructions of POLST needing to be signed. However, medical record contained the fully executed POLST. Patient 12: The aide care plan contained no instructions for use of shower chair/bench. Also, patient taking an anticoagulant; however, there was no evidence of instructions for bleeding precautions on the aide care plan. Patient 13: The aide care plan contained no instructions for use of shower chair/bench. Patient 14: Aide care plan contained tasks with frequencies of “as needed” and “PRN as requested”. However, patient unable to make decisions due to documented cognitive impairment. There was no evidence of instructions for documented dysphagia or bleeding precautions, as patient on anticoagulant. Also, aide care plan contained no instructions for patient’s use of wheelchair.”

“Upon patient record review 4 of 19 (Patient #1,#3,#5,#6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: The medical record contained an order for aide visits twice weekly. There was no evidence of second visit completed week of 8/2/26. Patient 3: During the home visit, the aide gave patient a shower and then transferred to wheelchair. However, there was no evidence of task for shower or wheelchair on the aide care plan. Patient 5: The medical record contained an order for aide visits twice weekly. There was no evidence of second visit completed week of 8/9/26. Patient 6: The medical record contained an order for aide visits twice weekly. There was no evidence of any aide visits completed week of 8/9/26.”

“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 Profile revised 4/2020 showed the patients receiving medications administered by the organization will have a current accurate medication profile in the clinical record. The medication profiles will be uploaded for each change to reflect current medications, and new and/or discontinued medications.Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.On 2/26/26 at 1030 hour, a home visit was conducted with RN 1 to the assisted living facility where Patient 1 resided. The current medication profile for Patient 1 included guaifenesin (expectorant) oral syrup 15 mg every four hours PRN for cough.However, review of the medications included in the patient’s administration record at the assisted living facility did not include the above medication.An interview and concurrent medication profile review was conducted with RN 1. RN 1 was informed and confirmed the patient’s medication profile was not updated.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that occurred since the initial assessments, information on the patients’ progress, and reassessment of the patients’ responses for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential of not addressing the care needs for these patients. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The plan of care must be initiated at start of care.1. Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.a. Review of the Skilled Nursing Visits notes showed the following:-On 7/2/25, the patient had multiple skin tears: right anterior lower leg, right posterior lower leg, right anterior upper arm, and right posterior upper arm. Wound care was provided to all four sites as follows: cleansed with normal saline, applied petroleum gauze, and covered with foam dressings. Wound evaluation had been referred to a wound care group due to prolonged healing.-On 7/24/25, wound care to the right arm was performed and was scheduled on a Monday/Wednesday/Friday rotation. The hospice SN would provide care on Mondays and Fridays, while a wound care nurse would complete the Wednesday visits.-On 10/13/25, the hospice was notified about the patient’s most recent wound, the right posterior leg skin tear of 0.5 cm.-On 10/20/25, an onset of the patient’s left arm skin tear.-On 12/1/25, an ecchymosis on the patient’s right and left shins.However, review of the IDG Meetings dated 7/10, 7/24, 8/5, 10/14, 10/28, and 12/9/25, showed no documented evidence the IDG discussed the patient’s multiple skin tears and wounds, and referral to wound care agency and the SN visits.b. Review of the MSW visit dated 12/24/25, showed MSW visit one time a month with PRN visits for support PRN.In addition, review of the IDG Meeting dated 1/6/26, showed an MSW discussion that there were no changes to the plan of care at this time. The MSW would continue to assess psychosocial needs and provide ongoing support as indicated. The frequency of MSW visits was one time monthly.Review of the IDG Meeting dated 1/20/26, showed MSW visits four PRN visits to assess and address psychosocial needs. However, there was no documented evidence the IDG had reviewed/discussed the reason why the MSW visits was changed to PRN.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 2/25/26. The clinical record showed SOC was 7/13/25. The patient was certified for hospice services during the certification periods from 7/13/25 to 10/10/25, 10/11/25 to 1/8/26, and 1/9/26 to 3/9/26.a. Review of the Progress Report from the wound care provider dated 10/29/25, showed the following information:- Wound care treatment on the left medial lower leg: cleanse the wound with cleanser and pat dry with gauze; apply Tetracyte (topical antibiotic ointment) and Silvasorb gel (used to treating pressure injuries, diabetic ulcers, lacerations and skin tears) to the wound bed, followed by collagen and oil emulsion gauze.; and cover with hydrocolloid dressing (wound dreeing) three times weekly and PRN for soiled or loose dressing.Review of the RN-Skilled Nursing Visit dated 11/3/25, showed wound care was provided to the left inner calf as per the wound care provider.However, review of the IDG meeting dated 11/11/25, showed no documented evidence the IDG discussed the patient’s wound care treatment on the left inner calf.b. Review of the MSW visit dated 12/29/25, showed MSW visits one time a month with PRN visits for support PRN.In addition, review of the IDG Meeting dated 1/6/26, showed the MSW discussion that there were no changes to the plan of care at this time. The MSW would continue to assess psychosocial needs and provide on-going support as indicated. The frequency of MSW visit was one time monthly.Review of the IDG Meeting dated 1/20/26, showed MSW visits four PRN visits to assess and address psychosocial needs. However, there was no documented evidence the IDG had reviewed/discussed the reason why the MSW visit was changed to PRN.On 3/11/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.3. Review of Patient 3’s clinical record was initiated on 2/26/26. The clinical record showed SOC was 7/17/25. The patient was certified for hospice services during the certification periods from 7/17/25 to 9/14/25, 9/15/25 to 11/13/25, 11/14/25 to 1/12/25, and 1/13/26 to 3/13/26.Review of the MSW visit dated 12/9/25, showed MSW visits one time a month with PRN visits for support PRN.Review of the IDG Meetings dated 12/9 and 12/23/25, 1/20, 2/3, and 2/17/26, showed MSW visits four PRN visits to assess and address psychosocial needs. However, there was no documented evidence the IDG had reviewed/discussed the reason why the MSW visit was changed to PRN.On 3/11/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.”

“Based on observation, interview, and record review, the hospice failed to ensure care and services were provided in accordance with the POCs for two of three sampled patients (Patients 1 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the written plan of care will contain, but not limited to, the following:A. Start of care dateB. Certification PeriodC. Patient demographicsD. DiagnosisE. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling.F. Reduction in risk factorsG. Functional limitationsH. Mental statusI. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriate.J. Nutritional requirementsK. PrognosisL. DME and medical supplies necessary to meet patient needsM. Frequency/Amount/Duration and type of servicesN. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesO. Individualized interventions to assist with end-of-life careP. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologicalsQ. Statement of treatment goalsR. Interdisciplinary group assessment of needsS. Pain and symptom management interventionsT. Drugs and treatments (including allergies)U. Physician-directed instruction to patient and family/caregiverV. Physician (or other authorized licensed independent practitioner) ordersW. Measurable outcomes anticipated from implementing and coordinating the plan of careX. Patient or representative’s level of understanding, involvement and agreement with the plan of careY. End-of-life preferencesZ. Anticipated discharge and bereavement care needs of the family1. Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.a. Review of Patient 1’s IDG Meeting dated 12/23/25 and 1/20/26, showed SN visits two times a week for 60 days with four PRN visits for symptom management and COC.Review of the SN Visit for Week 4 (12/28/25 to 1/3/26) and Week 7 (1/18/26 to 1/24/26) showed the SN had conducted a visit one time a week instead of two visits a week.Further review of the clinical record failed to show documented evidence the physician was informed of the missed visits and there was no attempt to reschedule the missed visits for those weeks.b. Review of the physician’s order dated 2/17/26, showed the following wound care order for the BLE scattered leg skin tears-SN or caregiver to clean and cover the open skin tears with bordered nonadherent gauze, wrap with Kerlix (used for wound care dressing), and secure with tape.On 2/26/26 at 1030 hours, a home visit was conducted with RN 1 to the assisted living facility where Patient 1 resided. RN 1 was observed providing wound care treatment on the patient’s BLE skin tear. RN 1 cleansed and covered the open skin tears with bordered and non-adherent gauze, wrapped with Kerlix and secured with tape, and wrapped the BLE with Coban (cohesive bandage that sticks only to itself).However, there was no documented evidence the physician had ordered the BLE to be wrapped with Coban.An interview was conducted with RN 1. RN 1 confirmed wrapping the BLE with Coban was not in the physician’s order.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.2. Review of Patient 3’s clinical record was initiated on 2/26/26. The clinical record showed SOC was 7/17/25. The patient was certified for hospice services during the certification periods from 7/17/25 to 9/14/25, 9/15/25 to 11/13/25, 11/14/25 to 1/12/25, and 1/13/26 to 3/13/26.Review of the Skilled Nursing Visit dated 11/22/25, showed a wound care treatment was provided to the patient’s bilateral feet. Documentation showed the wound care was performed as followed: cleansed thoroughly and patted dry, applied Opticell Ag fiber (wound dressing designed to manage moisture and kill bacteria in moderate to highly exudating partial and full thickness wounds) “2x2” to wound bed, covered with abdominal pad “5x9,” and secured with MedFix (water resistant retention tape) four dressing retention tapes.However, there was no documented evidence the physician had ordered a wound care treatment for the bilateral feet.Review of the Skilled Nursing Visit dated 1/5/26, showed wound care treatment was provided as follows:-For coccyx wound: cleaned with wound cleanser, patted dry, applied calcium alginate (highly absorbent sterile wound dressings that turn into a gel upon contact with moderate to heavy wound exudate) with silver and honey, and covered with a foam dressing.However, there was no documented evidence the physician had ordered the above wound care treatment for the coccyx.On 3/11/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for one of three patients (Patient 1). This failure had the potential to not providing care and services to meet the patient’s care needs. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the written plan of care will contain, but not limited to, the following:A. Start of care dateB. Certification PeriodC. Patient demographicsD. DiagnosisE. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement, and counselingF. Reduction in risk factorsG. Functional limitationsH. Mental statusI. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriateJ. Nutritional requirementsK. PrognosisL. DME and medical supplies necessary to meet patient needsM. Frequency/Amount/Duration and type of servicesN. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesO. Individualized interventions to assist with end-of-life careP. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologicalsQ. Statement of treatment goalsR. Interdisciplinary group assessment of needsS. Pain and symptom management interventionsT. Drugs and treatments (including allergies)U. Physician-directed instruction to patient and family/caregiverV. Physician (or other authorized licensed independent practitioner) ordersW. Measurable outcomes anticipated from implementing and coordinating the plan of careX. Patient or representative’s level of understanding, involvement and agreement with the plan of careY. End-of-life preferencesZ. Anticipated discharge and bereavement care needs of the familyReview of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.Review of the RN-Skilled Nursing Visit dated 7/2/25, showed the patient had multiple skin tears on the right anterior lower leg, right posterior lower leg, right anterior upper arm, and right posterior upper arm. Documentation showed wound care was provided to all four sites as follows: cleansed with normal saline, applied petroleum gauze, and covered with foam dressings. Documentation showed wound evaluation had been referred to a wound care provider due to prolonged healing.Furthermore, review of the RN-Skilled Nursing Visit dated 7/24/25, showed wound care on the right arm was performed and was scheduled for a Monday/Wednesday/Friday rotation. Documentation showed the hospice SN would provide care on Mondays and Fridays, while a wound care nurse would complete the Wednesday visits.*However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s multiple skin tears and the referral to a wound care provider.Review of the Physician’s Order dated 1/11/26, showed a new order for Ciprofloxacin (antibiotic ) ophthalmic solution 5 ml one drop into the left eye every four hours for 10 days for eye infection.In addition, the Physician’s Order dated 1/12/26, showed a new order for Cephalexin (antibiotic) capsule 500 mg one capsule by mouth twice daily for seven days for the left eye periorbital cellulitis.*However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s left eye infection.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.”

“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 for not evaluating the POCs and providing appropriate care and services to these patients. 1. Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.Review of the IDG Meetings dated 6/26, 7/10, 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, and 12/23/25; 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified problems with established goals and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 1 had a care plan problem addressing the risk for hyperglycemia and hypoglycemia due to diabetes disease process. Documentation showed one of the goals was for the patient’s blood glucose level to be maintained at an optimal level for patient’s disease process throughout the episode. There was no documented evidence as to what optimal level of blood glucose was for the Patient 1.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. They acknowledged and verified the findings.2.Review of Patient 2’s clinical record was initiated on 2/25/26. The clinical record showed SOC was 7/13/25. The patient was certified for hospice services during the certification periods from 7/13/25 to 10/10/25, 10/11/25 to 1/8/26, and 1/9/26 to 3/9/26.Review of the IDG Meetings dated 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, and 12/23/25, 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified problems with established goals and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 2 had a care plan problem addressing the patient’s back pain. Documentation showed one of the goals was for the patient to remain at an acceptable pain level throughout the benefit period. There was no documented evidence as to what the acceptable pain level was for the patient.On 3/11/26 at 1000 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. They acknowledged and verified the findings.3. Review of Patient 3’s clinical record was initiated on 2/26/26. The clinical record showed the SOC was 7/17/25. The patient was certified for hospice services during the certification periods from 7/17/25 to 9/14/25, 9/15/25 to 11/13/25, 11/14/25 to 1/12/25, and 1/13/26 to 3/13/26.Review of the IDG Meetings dated 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, and 12/23/25, 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified problems with established goals and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 3 had a care plan problem addressing anxiety. Documentation showed one of the goals was for the patient/caregiver to verbalize knowledge of measures to reduce anxiety. There was no documented evidence as to what the measures were to reduce anxiety.On 3/11/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. They were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’ 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 Group Meeting revised 4/2020, showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.1. Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.Review of the IDG Meetings dated 6/26, 7/10, 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified care plan problem included incontinence of urine with high risk for UTI, bowel incontinence that will impact quality of life, difficulty swallowing or history of aspiration due to disease process, depression that interfere with functional activity of quality of life, psychological, no individual emergency plan, increase risk of fdalls, risk for hyperglycemia and hypoglycemia due to diabetes disease process, and risk for weight loss due to disease process. The care plan problems were created on 6/13/25.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the RN-Skilled Nursing Visit dated 1/6/26, showed the patient was sitting on the floor in the room, possible fall.There was no documented evidence the identified care plan problems for the increased risk of falls was updated.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. The ED stated the POC should be updated every 15 days. They acknowledged and verified the findings.2.Review of Patient 2’s clinical record was initiated on 2/25/26. The clinical record showed SOC was 7/13/25. The patient was certified for hospice services during the certification periods from 7/13/25 to 10/10/25, 10/11/25 to 1/8/26, and 1/9/26 to 3/9/26.Review of the IDG Meeting dated 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified care plan problems included COVID-19 infection control and education, incontinence of urine with high risk for UTI and skin breakdown, depression, dyspnea, pain, difficulty swallowing, increased risk of falls, and risk for weight loss. The identified problems were opened on 7/13/25.There was no documented evidence the identified problems were updated to provide appropriate care for the patient.On 3/11/26 at 1000 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. The ED stated the POC should be updated every 15 days. They acknowledged and verified the findings.3. Review of Patient 3’s clinical record was initiated on 2/26/26. The clinical record showed SOC was 7/17/25. The patient was certified for hospice services during the certification periods from 7/17/25 to 9/14/25, 9/15/25 to 11/13/25, 11/14/25 to 1/12/25, and 1/13/26 to 3/13/26.Review of the IDG Meetings dated 7/24, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, 1/20, 2/3, and 2/17/26, showed the patient’s identified care plan problems included altered mental status, anxiety, bowel elimination, constipation, fluid overload, fall risk, hyperglycemia /hypoglycemia, and nutrition. The care plan problems were created on 7/17/25.There was no documented evidence the identified problems were updated.On 3/11/26 at 1030 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. They acknowledged and verified the findings.”

“Based on observation, interview, and record review, the hospice failed to ensure the IDG maintained responsibility for directing and supervising the care and services provided for one of three sampled patients (Patient 1). This failure had the potential of not addressing the care needs for this patient. Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 4/2020 showed the interdisciplinary group responsibility include among others: participation in the establishment of the plan of care for each patient admitted to the hospice service, participation in the periodic review and updating of the plan of care for each patient receiving hospice services, provision and/or supervision and coordination of hospice care and services, and establishment and implementation of policies and procedures governing the day-to-day provision of hospice care and services.1. Review of Patient 1’s clinical record was initiated on 2/24/26. The clinical record showed the SOC was 6/13/25. The patient was certified for hospice services during the certification periods from 6/13/25 to 9/10/25, 9/11/25 to 12/9/25, 12/10/25 to 2/7/26, and 2/8/26 to 4/8/26.a. Review of the Skilled Nursing Visits notes showed the following information:-On 7/2/25, the patient had multiple skin tears on the right anterior lower leg, right posterior lower leg, right anterior upper arm, and right posterior upper arm. Documentation showed wound care was provided to all four sites as follows: cleansed with normal saline, applied petroleum gauze, and covered with foam dressings. Documentation showed wound evaluation had been referred to a wound care provider due to prolonged healing.-On 7/24/25, the wound care to the patient’s right arm was performed and was scheduled on a Monday/Wednesday/Friday rotation. Documentation showed the hospice SN would provide care on Mondays and Fridays, while a wound care nurse would complete the Wednesday visits.-On 10/13/25, the hospice was notified about the patient’s most recent wound. Documentation showed the patient’s right posterior leg had a skin tear of 0.5 cm.-On 10/20/25, the onset of the patient’s left arm skin tear.-On 12/1/25, the ecchymosis on the patient’s right and left shin.However, there was no documented evidence the prolonged healing of the wound, referral to a wound care provider, and multiple skin tears and wounds were coordinated with the IDG.b. Review of the hospice’s P&P titled Standard Precautions revised 4/2020 showed gloves are to be changed: between tasks and procedures on the same patient and after removing an old dressing. On 2/26/26 at 1030 hour, a home visit was conducted with RN 1 to the assisted living facility where Patient 1 resided. RN 1 was observed providing wound care treatment to the patient’s BLE skin tear. RN 1 was observed to use gloves to perform wound care. RN 1 removed the old dressing and performed the wound care treatment for Patient 1.However, RN 1 did not change the gloves after removing the old dressing to perform wound care treatment on Patient 1, which was not consistent with the P&P.*The IDG failed to maintain the responsibility of supervising the care and services as the hospice’s P&P was not implemented.On 3/11/26 at 0905 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The ED and DPCS were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the POC included the measurable outcomes specific for the patient’s care needs identified in the assessment for one of one sampled patient (Patient A). This failure created the risk of not providing necessary care and services to this patient. Findings: Review of Patient A’s clinical record was initiated on 12/3/24. The clinical record showed the SOC was 2/24/24. The patient was certified for hospice services during the certification periods from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25. The POC, for the certification periods from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25, showed the lists of the patient’s care needs. However, the POC failed to include the measurable outcomes for each of the patient’s care needs. For example, the documentation showed the following: - The goal for nutrition was to have an optimal nutrition/hydration based on disease progression. - The goal for pain was to remain at acceptable level throughout the benefit period.- The goal for fall was to maintained in a safe environment throughout episode of care.- The goal for oxygen therapy was to have a good understanding of use of oxygen equipment within one week. However, there were no documented evidence what the optimal or acceptable level, a safe environment, and a good understanding were for the patient to achieved these goals. On 12/5/24 at 1000 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if the identified goals were measurable. They reviewed the clinical record and the Executive Director replied no, the goals were not measurable. They were informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the POC included the specific instructions related to the pain medications for one of one sampled patient (Patient A). This failure created the risk of not providing necessary care to this patient. Findings: Review of Patient A’s clinical record was initiated on 12/3/24. The clinical record showed the SOC was 2/24/24. The patient was certified for hospice services during the certification periods from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25. The POC, for the certification period from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25, showed the medication list. The medication list included the following PRN pain medications. Norco (analgesics, opioid) 5-325 mg one tablet PO Q6H PRN for pain, Tylenol (analgesics) 8 hour arthritis pain oral tablet extended release 650 mg two tablets PO Q8H PRN for pain Diclofenac sodium external gel (non-steroidal anti-inflammatory medication) 1% apply a thin layer to affected area TID PRN for pain. However, the instructions for the PRN pain medications were not specific for the level of pain. On 12/5/24 at 1000 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if the instructions for the PRN pain medications were specific. The Executive Director replied no. They were informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided to one of one sampled patient (Patient A). This failure created the risk of not providing quality care for this patient. Findings: The hospice’s P&P titled Interdisciplinary Group Meeting revised 5/2023, showed the purpose was to define the process for interdisciplinary group meetings and documenting patient status in the clinical record. The procedure includes the patient plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires and any special needs of the patient. Review of Patient A’s clinical record was initiated on 12/3/24. The clinical record showed the SOC was 2/24/24. The patient was certified for hospice services during the certification periods from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25. a. Review of the SN notes dated 10/17/24, showed the patient had crackles lung sound on the upper lobes. Review of the SN narrative notes dated 10/17/23, showed the patient was sent to the acute care hospital emergency department for evaluation. However, there was no documented evidence this condition was coordinated to the IDG on 10/31/24. In addition, there was no documented evidence the IDG had discussed or revised the POC to address the respiratory problems. On 12/4/24 at 1047 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if the IDG had revised the POC to reflect the patient’s respiratory problems. They reviewed the clinical record and the Patient Care Coordinator replied no, there will be one next time. They were informed and acknowledged the finding. b. Review of the SN notes dated 10/23/24, under the section of the narrative notes, showed the patient was recently in the acute care hospital emergency department for seizures and was prescribed Depakote (antiseizure medication). The notes also showed the PCG cut the medication in half because it was making the patient sleepy. Review of the IDG Meeting dated 10/31/24, under the section of medication management, showed a teaching was provided related to antiseizure medication . However, there was no documented evidence the IDG had discussed or revised the POC to address the patient’s seizure. Moreover, review of the clinical record failed to show documented evidence the physician was notified that the Depakote was making the patient sleepy so the PCG cut the Depakote dose in half. On 12/4/24 at 0935 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if the IDG had revised the POC to reflect the recent seizure activity. They reviewed the clinical record and the Executive Director replied no. They were informed and acknowledged the finding. c. Review of the Care Communication dated 10/4, 10/7, 10/9, 10/10, 10/14, and 10/15/24, showed discussions related to the patient discharge from the hospice. However, review of the IDG Meeting Notes dated 10/17, 10/31, 11/14, and 11/28/24, failed to show documented evidence the IDG had discussed discharge planning. On 12/4/24 at 1021 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if discharge planning was discussed in the IDG meetings. The Patient Care Coordinator reviewed the clinical record and replied there were communication notes; however, discharge planning was not discussed in the IDT meetings. They were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure one of one sampled patient (Patient A) or PCG was informed of the PT services discontinued. This failure created the risk of not addressing the care needs for this patient. Findings: Review of Patient A’s clinical record was initiated on 12/3/24. The clinical record showed the SOC was 2/24/24. The patient was certified for hospice services during the certification periods from 9/21/24 to 11/19/24, and 11/20/24 to 1/19/25. Review of the SN visit notes dated 10/23/24, showed the patient had weakness, difficulty in ambulating, limited mobility, poor balance, and chair bound. The narrative notes showed the patient was assessed for the need of PT evaluation. However, review of the clinical record failed to show documented evidence of a PT evaluation. In addition, review of the Face to Face Non-Certifying Notes dated 10/30/24, on the narrative notes section, showed a PT order was placed for safety as the family expressed concerns regarding unsteady gait and fall risk. Review of the Physician’s Order dated 11/1/24, showed to discontinue PT. However, review of the clinical record failed to show documented evidence the discontinuation of PT was communicated to the patient/PCG. On 12/5/24 at 0855 hours, an interview and concurrent clinical record review was conducted with the Executive Director and Patient Care Coordinator. They were asked if the patient had PT services. They reviewed the clinical record and the Patient Care Coordinator replied yes, the patient had PT since admission but it was discontinued. They were also asked if the discontinuation of PT was communicated to the patient/PCG. The Patient Care Coordinator replied no, it was not on the communication notes. They were informed and acknowledged the finding.”