Santa Rosa Hospice

“Upon patient record review 3 of 14 (Patient #1, #2, #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: Patient admitted on 7-30-25 the psychosocial initial assessment was not completed until 8-5-25 which was outside of the 5 day requirement. Patient #2: Patient admitted on 4-25-26 the psychosocial initial assessment was not completed until 5-2-26 which was outside of the 5 day requirement. Patient #4: Patient admitted on 3-6-26 the psychosocial initial assessment was not completed until 3-12-26 which was outside of the 5 day requirement.”

“Upon patient record review, 4 of 14 (Patient #1, #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 #1, #8, #10 : The medication profile included diclofenac 1% gel to be applied 3 times a day to affected area without evidence of a specific location. Patient #9: The medication profile included diclofenac 1% gel to be applied 3 times a day to affected area without evidence of a specific location. Also Mupirocin 2% to apply thin layer to affected area once daily as ordered in treatment. This patient has multiple wounds identified within the medical record with no evidence indicating which wound to apply the medication.”

“Upon patient record review, 2 of 14 (Patient #1, #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: The patient was admitted on 7-30-25. The record indicated the bereavement assessment was completed on 8-6-25 which is greater than the 5 day requirement. Patient #2: The patient was admitted on 4-25-26. The record indicated the bereavement assessment was completed on 5-1-26 which is greater than the 5 day requirement.”

“Upon patient record review, 4 of 14 (Patient #1, #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 #1, #8, #10: The record indicated an order for Diclofenac 1% to be applied 3 times a day to affected area without evidence of a specific location identified. Patient #9: The record indicated an order for Diclofenac gel 1% to be applied 3 times a day to affected area without evidence of a specific location identified. Also, Mupirocin 2% topical gel apply thin layer to affected area once daily as ordered in treatment. This patient has multiple wounds documented in the medical record, the order is lacking which wound to apply the medication.”

“Upon patient record review, 3 of 14 (Patient #3, #4, #5) 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 #3: Documentation was noted by the nurse the patient utilized a bed side commode and required the use of a transport chair and wheelchair with foot rests for mobility. The aide care plan was not updated to include this equipment. Patient #4: Documentation noted in the nursing narrative on 8-7-26 states the patient was bedbound. Instructions were provided to the family by the nurse to keep side rails up for patient safety. There was no evidence the aide care plan was updated to include side rails or contained instructions to ensure side rails placed up after cares. Patient #5: Documentation noted in the nursing note stated the patient had a wound. There was no evidence the aide plan of care was updated to include the location of the wound or to notify the RNCM if the adhesive dressing was soiled or became wet or dislodged during cares.”

“Upon patient record review 1 of 14 (Patient #2) 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 #2: Multiple aide visits were identified but not limited to 7-29-26 noting the aide provided cares not indicated on the aide care plan. Some examples included: Active range of motion, passive range of motion, wound / skin care, foley maintenance; however, the patient did not have a wound or foley”