Carelife Hospice Inc.

“Observed in Record Review. In 8 of 16 patient records reviewed, It was noted throughout the review of patient records, goals did not contain specific individualized information that can be used to accurately measure if the patient is progressing toward achieving their goals. During D/CRR#1 the hospice nurse surveyor noted the following goals were not measurable to assess if achievable or achieved: Caregiver will verbalize having elimination needs met at an acceptable level, Manage and alleviate symptoms of acid reflux/GERD, Patient will remain free from distress secondary to bladder incontinence, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Patient will remain free from distress secondary to weakness, Patient will remain free from distress secondary to pain. During RRD/C#2 an example of the goals identified on the POC that were not measurable were as follows: Changes in cardiac status will be identified and managed, Patient/caregiver will verbalize understanding of measures to manage cardiac symptoms, Patient will maintain optimal mobility, Caregiver will verbalize having elimination needs met at an acceptable level. During RRHV#1 an example of the goals on the POC that were not individualized as follows: The primary caregiver will express her needs and concerns for processing, Patient will obtain optimal amounts of sleep. Caregiver will verbalize understanding of measures to manage shortness of breath. Changes in respiratory status will be identified and managed. During RRHV#2 the following goals were not individualized with measurable outcomes: Patient will maintain a bowel pattern that promotes comfort and minimizes constipation related distress during the next 14 days. Son getting cremation information to social worker. During RR#2 it was noted some goals were not measurable to assess if achieved as follows: Patient will remain free from distress secondary to weakness. Patient will obtain optimal amounts of sleep. During RR#4 it was noted the following goals without measurable outcome time frames to assess if there was progress toward achieving the goals: Patient will remain free from distress secondary to weakness, Pt will remain free from distress secondary to poor appetite. During RR#5 it was noted the following goals without measurable outcome time frames to assess if there was progress toward achieving the goals: Patient will remain free from distress secondary to weakness, Increase strength/energy for functional activities, Patient will remain free from distress secondary to anxiety, Patients needs will be safely met, Pt will remain free of injury. During RR#8 it was noted lack of measurable outcome time frames on goals, for example: caregiver will demonstrate understanding of feeding assistance and aspiration precautions. This was discussed with the Administrator/DPCS.”

“Observed in Record Review. In 4 of 16 patient records reviewed, During RR#4 the hospice nurse surveyor noted lack of wound care interventions added to the POC to accomplish the stated goals. During RR#5 it was noted lack of pain interventions on the POC to accomplish the stated goals. During RR#6 it was noted an order for Plavix however, the POC lacked of interventions on s/s bleeding and bleeding precautions. The POC included dressing change orders for the G-tube however, there was lack of interventions and goals on the POC related to family education on peristomal skin condition, s/s infection, redness or leaking. During RR#7 it was noted the patient was prescribed Plavix however, there was lack of interventions on the POC related to s/s bleeding and bleeding precautions. This was discussed with the Administrator/DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, During RRHV#3 it was noted by the hospice nurse surveyor that the patient POC endocrine section was not updated to reflect that the patient diabetic medications were discontinued in February 2026. The diabetic care interventions and goals were included on the current POC. This was discussed with the Administrator/DPCS.”

“Observed in Record Review. In 2 of 16 patient records reviewed, During RRD/C#2 and RRHV#1 the hospice nurse surveyor noted incomplete orders for pain control medication. RRD/C#2 patient was prescribed Tylenol 325 2 tabs for mild pain and Tylenol#3 TID PRN pain. The Tylenol #3 medication lacked the direction on when to administer the medication based on pain level. During RRHV#1 it was noted an order for Acetaminophen 500mg Tablet 1 Tab Oral Every 6 hours PRN Moderate Pain, Acetaminophen 500 mg tablet 2 tabs every 6 hours PRN severe pain and Norco 5mg-325mg Tablet 1 tablet Oral every 12 hours prn pain management. The Norco order lacked the direction of when to administer the medication. This was discussed with the Administrator/DPCS.”

“Observed in Record Review. In 3 of 16 patient records reviewed, During RR#2 the hospice nurse surveyor noted the wound care order procedure was not documented on SN notes. The SN documented: SN completed ordered wound care to the left and right buttocks and left hand/palm. During RR#4 it was noted the SN documented wound care procedure orders as follows: SN performed wound care on patient right buttock as ordered. During RR#10 it was noted the wound care procedure order provided by the SN was documented as follows: Provided treatment to all wounds as ordered. This was discussed with the Administrator/DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, During RRD/C#2 it was noted by the hospice nurse surveyor the following: Pcg will verbalize/demonstrate understanding of safe care of Indwelling foley cath to prevent urinary tract infection for the next 14 days however, there was lack of clinical documentation of the presence of a foley catheter. This was discussed with the Administrator/DPCS.”

“Based on observation, interview, and record review, the hospice agency failed to ensure the hospice agency operates in a location approved by the Centers for Medicare and Medicaid Services (CMS) prior to providing hospice care and services to the patients, when: 1. The hospice agency location address was not approved by the Centers for Medicare and Medicaid services; 2. The patient admission packet and pamphlets/brochure contained the name and address of the unapproved location; 3. The unapproved location was being utilized for staff to drop off and pick up patient documents and supplies; 4. The unapproved location utilized permanent staff to perform office duties; and 5. The location was not approved by the hospice agencys Governing Body. The cumulative effect of this systemic practice resulted in the potential for patients to receive care and supplies from an unapproved location and without the oversight of the parent organization. Findings: On February 10, 2025, at 10:30 a.m., an unannounced visit was conducted to investigate a complaint regarding the use of an unapproved hospice agency location. On February 10, 2025, at 11:06 a.m., a review of the hospice agencys census indicated 93 patients being serviced by the hospice agency. The list of current patients indicated most of the patients reside in Apple Valley and only three patients reside in Riverside. On February 10, 2025, the hospice agency documents were reviewed. A review of the hospice agencys pamphlet/brochure and patient admission packet indicated two location addresses (Riverside and Apple Valley). A review of the hospice agencys Governing Body meeting minutes for the following dates did not indicate approval of a “;drop off location,” located at Apple Valley: - January 13, 2023; - April 21, 2023; - July 21, 2023; - November 3, 2023; - January 31, 2024; - April 18, 2024; - July 26, 2024; and - November 29, 2024. On February 10, 2025, at 2:12 p.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated the Apple Valley location was not considered an office but “;just a drop location.” The DPCS stated the “;drop off location” have a staff member working there to hand out supplies when nurses come in, and for the Marketing staff to pick up paperwork and scan patients documents to be sent to the Riverside office. On February 11, 2025, at 8:30 a.m., an unannounced visit was conducted at the Apple Valley location and was greeted by the receptionist and the Administrator (ADM). On February 11, 2025, at 8:40 a.m., during an interview with the ADM, he stated he traveled back and forth between the two agency locations (Riverside and Apple Valley). The ADM stated he would come to the Apple Valley location to conduct meetings with medical members and when marketing for patients. On February 11, 2025, at 8:46 a.m., during an interview with the receptionist, she stated she worked full time at the Apple Valley location. On February 11, 2025, at 8:53 a.m., an observation was conducted of the Apple Valley location. The following were observed: - Two computer screens and an iPad were observed to the right of the reception area; - A meter reader for mail was observed next to the reception desk; - Three desks with a computer and chair for each desk; - A refrigerator/freezer containing food and drinks; - A table with chairs and cabinet with coffee pot and condiments; - A copier and fax machine were observed in the center of the room; - An enclosed office where the ADM conducted business; - An enclosed area with multiple boxes and cabinets containing medical supplies; - One five-shelf cabinet containing binders for new patients and a shelving unit with small slots to hold paper needed for admission packets. On February 11, 2025, at 9 a.m., the ADM was observed to conduct a conference call with a medical group. On February 11, 2025, at 9:30 a.m., during an interview with the receptionist (RC), a chair was observed to have bags of supplies. In a concurrent interview with the RC, she stated those bags of supplies were supplies requested by the nurses to pick up. On February 11, 2025, at 9:35 a.m., the receptionist desk was observed to have a computer screen showing schedule of patient visits. On February 11, 2025, at 10 a.m., the ADM stated there is no business license for the Apple Valley location as it is being used a “;drop off location.” The ADM stated he would usually spend three to four days in a week at the Apple Valley location. On February 11, 2025, at 10:44 a.m., a follow up interview was conducted with the RC. The RC stated she conducted the following administrative duties: - Ordering and fixing patient supplies, preparing the patient supplies for the nurses pick up; - Assist in ordering DME (durable medical equipment – medical equipment and supplies ordered by the healthcare provider for a patients routing or long-term use such as bed, wheelchair, walker, etc.); -Answer phone calls from patients, staff, and providers; - Assist in scheduling patient visits; and - Providing copies of the patients medication list or plan of care to the nurses. On February 19, 2025, at 2:05 p.m., a review of the hospice agency admission packet and hospice agency pamphlet was conducted with the ADM and the Director of Patient Care Services Designee (DPCSD). The ADM and the DPCSD were shown the hospice agency admission packet and the hospice agency pamphlet. The ADM and the DPCSD stated the hospice agency admission packet and the hospice agency pamphlet each had information which consisted of two different phone numbers for two different office locations. Neither the hospice agency admission packet nor the hospice agency pamphlet had identified themselves as a location only used as a drop site. On February 19, 2025, at 2:08 p.m., a follow up interview was conducted with the ADM. The ADM acknowledged there should be a meeting of the governing body addressing the drop site location. On February 19, 2025, at 2:12 p.m. an interview was conducted with the DPCSD. The DPCSD stated the RC at the drop site location assisted with the scheduling. The DPCSD stated usually there are two other staff members that do most of the DME ordering. A review of the undated hospice agencys policy and procedure titled, “;Governing Body,” indicated, “;...the Governing Body will assume full legal authority, responsibility, and accountability of the overall management and operations, the provision of services, fiscal operations, review of the organizations budget and its operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body will serve as the governing authority for the care program, which will function according to the companys bylaws...the Governing Body will assist with development and approve strategic, marketing, and operational plans...that clear expectations for patient safety are established, implemented, and maintained...that any findings of fraud or waste are appropriately addressed...” A review of the undated hospice agencys policy and procedure titled, “;Organizational Planning,” indicated, “;...clearly defining long-range, strategic, and operational plans...resources needed provide and support care and services...organizational leadership will communicate leadership regarding operational and clinical issues on a routine basis...development of long-range, strategic and operational plans which include all care and services to be provided, based on the organizations mission and philosophy...management of information...The Governing Body and senior management will communicate the organizations plan to personnel on a regular basis. All hospice personnel will have an opportunity to communicate with senior management regarding operational and clinical issues on a routine, scheduled basis...” A review of the undated hospice agencys policy and procedure titled, “;Staffing and Scheduling,” indicated, “;...Continuity of care is fostered by assigning consistent personnel to the patient whenever possible...the Clinical Supervisor/Nursing Supervisor will review the patient census and staffing levels on a daily basis and will make patient assignments which consider...geographical area...patient load...clinicians will contact the office daily to confirm their schedule for the day...receive any necessary reports on patient to be visited...if an emergency arises or if any organization personnel are ill and it is impossible to fulfill their obligations, it is mandatory that the organization personnel contact the organization as soon as possible to report the absence...” A review of the undated hospice agencys policy and procedure titled, “;Durable Medical Equipment and Supplies,” indicated, “;...the durable medical equipment needed for an individuals support to stay at home will be obtained from a hospice-approved company if the patient is on Medicare, Medicaid, or private insurance hospice benefit...those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company if the patient is on Medicare, Medical, or private insurance hospice benefit...” A review of the undated hospice agencys policy and procedure titled, “;Administrator,” indicated, “;...operational planning and budgeting...ensuring organizational compliance with legal, regulatory, and accreditation requirements...establishing and maintaining effective channels of communication, including integrations of technology, as applicable...ensuring appropriate staff supervision during all service hours...monitoring service utilization to ensure delivery of comprehensive care...monitoring operational progress toward accomplishing operational and strategic goals...insuring appropriate data collection and regular, complete reports are received by the Governing Body...ensuring availability of adequate space, equipment, and supplies...” A review of the undated hospice agencys policy and procedure titled, “;Job Description-Hospice Administrator,” indicated, “;...the hospice Administrator organizes and directs the functions with overall responsibility for day-to-day operations, comply with applicable rules and regulations and reporting to the Governing Body. They implement the organizations purposes in a manner consistent with the goals, objectives, and policies established by the Governing Body...reports to governing body and acts on recommendations of authorized planning, regulatory and inspecting agencies, and contracted managed care organization...ensures accuracy of public information materials and activities...””