Optimal Care Hospice, Inc.

“Upon patient record review, 1 of 14 (Patient #4) 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: Patient has order for Oxygen concentrator and Oxygen 2-5 LPM via NC. Problems, goals interventions do not reference Oxygen safety precautions, but only O2 therapy as needed, under respiratory problem.”

“Upon patient record review, 4 of 14 (Patient #5, 6, 8, 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 #5: 8/8/24: SN to instruct pt/cg to hold medication if BS is less than 100 mg/dl and SN to instruct pt/cg to hold medication if systolic BP is less than 100 mg/hg. Not specified which med to hold and not consistent with specific parameters on each specific medication. Patient is on Glipizide and Farxiga for DM. Patient #6: 12/20/24 SN to instruct pt/cg to hold medication if BS is less than 100 mg/dl and SN to instruct pt/cg to hold medication if systolic BP is less than 100 mg/hg. Not specified which med to hold and not consistent with specific parameters on each specific medication. (Patient on Janumet and Glipizide for DM2 and on Olmesartan, Medoxomil/Hydrochlorothiazide, Carvedilol for hypertension.) Patient #8: 6/18/25 SN to instruct pt/cg to hold medication if BS is less than 100 mg/dl and SN to instruct pt/cg to hold medication if systolic BP is less than 100 mg/hg. Not specified which med to hold and not consistent with specific parameters on each specific medication. Medication parameters are different on individual meds: Example Hydralazine for hypertension -hold if systolic blood pressure is less than 110 mm hg. Patient #10: 6/22/25 SN to instruct pt/cg to hold medication if BS is less than 100 mg/dl and SN to instruct pt/cg to hold medication if systolic BP is less than 100 mg/hg. Not specified which med to hold and not consistent with specific parameters on each specific medication. Losartin Potassium 100 mg. alert says hold if systolic blood pressures is <110 mm hg. 7/1/25 “Gentacidin” 0.3% Ophthalmic solution 5 “get” BID x10 days for conjunctivitis. Order does not specify one or both eyes. 6/22/25 Order: Caregiver may provide skin care on non-nurse days. This order is not clear/specific.”

“Upon patient record review, 1 of 14 (Patient #10) 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 #10: Admitted 6/22/25. IDG Care Plan problems, goals and interventions include coccyx wound. Patient developed heel and ankle wounds, but problems, goals and interventions not updated to reflect additional wounds. 7/1/25 Order for antibiotic ophthalmic solution related to conjunctivitis. There was no update to problems, goals and interventions at that time.”

“Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 9/25/25 Initial RN comprehensive assessment, the RN documented need for SC and MSW visits. 9/25/25 order for MSW initial assessment within 5 days of admission to assess for psychosocial needs and Spiritual Care Coordinator for Spiritual assessment within 5 days of admission to identify spiritual needs support to patient, family and primary caregiver. IDG 9/25/25 and 10/10/25 says SC will follow up 1x/month and MSW says within 5 days from SOC then monthly and as needed. No documented evidence any visits have been made and/or no evidence patient refused visits.”

“Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #10: Admitted 6/22/25 with existing pressure ulcer Coccyx/sacral area. Orders to cleanse with clean water and mild soap. Pat dry and apply Calmoseptine every diaper change and as needed. 6/22/25 Medical Director Referral to Rapid Mobile Recovery for consult and specialized treatment. First visit 6/24/25. Recommended treatment to cleanse with normal saline, apply Santyl and calcium alginate. Calmoseptine as barrier cream and apply bordered foam dressing. Wound care company to visit weekly and otherwise treatment daily by hospice and/or facility caregiver 7/5/25 visit by Mobile Rapid Recovery addresses right heel wound and right ankle wound also. Recommended treatment cleanse with normal saline and apply bordered foam dressing. Change daily and as needed. The IDG problems, goals and interventions were not updated to include the heel and ankle wounds or any of the recommended wound care treatments. There was no documented acknowledgment of the visits made by the wound care provider in IDG notes or SN visit notes. 7/6/25 RN visit narrative states “Skin assessment done and patient presented with unstageable wound to coccyx. Wound care specialist to evaluate and treat as indicated.” Wound care company had already seen patient twice by this date. The SN visit note continued with ... Previous pressure ulcers to coccyx now healed. Instructed PCG to implement measures to prevent skin breakdown such as repositioning at least every 2 hrs. unless contraindicated….”. No reference to specifics of wound care or teaching related to wound care. Wound care company performed debridement the prior day 7/5/25, documenting sacral open wound... unstageable, not healed and scanned wound pictures during that visit, in addition to recommended daily wound care.”

“Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel #4: Competency generally identifies shampoo, and not specific types.”

“Upon patient record review, 6 of 14 (Patient #1, 2, 4, 5, 7, 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: 8/15/25 Aide care plan/assignment includes Oxygen 2 LPM via NC prn, but there is no reference to Oxygen safety precautions. Frequency initially 1/wk. 9/1/25 order to increase to 2xwk. Frequency on assignment not updated to reflect increase. IDG frequency updated and Aide appropriately providing visits 2x/week. Patient #2: Aide care plan/assignment includes Oxygen 2 LPM via NC prn, but there is no reference to Oxygen safety precautions. Patient #4: Aide care plan/assignment includes Oxygen 2-5 LPM via NC prn, but there is no reference to Oxygen safety precautions. Patient #5: Aide assignment includes Oxygen flow rate of 2-5 LPM PRN, but no reference to Oxygen safety precautions. Patient #7: Patient has Eliquis prescribed, but Aide care plan/assignments do not include bleeding precautions. Patient #10: Aide care plan/assignment includes Oxygen 3 LPM via NC prn, but there is no reference to Oxygen safety precautions. Also, includes task to Encourage fluids as tolerated if not contraindicated. Direction to Aide is unclear in this assignment.”

“Upon contract review, 1 of 5 (Mobile Rapid Recovery) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care Upon observation, noted Medical Director made referral to wound care specialist for Patient #10. Assessment and specialized wound care provided weekly x 2. Contract presented to surveyor was actually a Business Associate Agreement. The agreement has no effective date and no dates for signatures. Surveyor provided education to administrator related to need for contractual agreement. No such contract provided by end of survey. (Additionally, there was no documented evidence by physician/IDG to determined if wounds related or not related to hospice diagnosis/prognosis).”

“Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #14: CTIs dated for benefit periods 7/2/22-9/28/22 as first 90 day period and 9/30/22-12/28/22 as 2nd 90 day period. Dates are not correct as there is a lapse from 9/28-9/30.”

“Upon patient client record review, 10 of 14 (Patient #1,3, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: Patient signed Hospice Election statement, hard copy - with blank to begin on.... date. A second form identified as Election of Hospice Medicare Benefit and Patient Authorization also has allocated space for benefit to begin on... and that date is also blank. Patients #1, 6, 7, 8, 9, 10, 11, 12, 13: Patient requested Notice of Non-Covered Items and Services, but form signed blank and no evidence it was completed and provided.”

“Upon patient client record review, 3 of 14 (Patient #4, 5, 13) did not have evidence that each patient record contains Advance Directives. Patient #4: EMR Code Status is DNR. 12/26/24 order for POLST Do not resuscitate. DNR POLST form signed and on file, but Section A - neither Attempt Resuscitation/CPR or Do Not Attempt CPR is checked. Patient #5: EMR Code Status is DNR. 8/8/24 POLST Do not resuscitate. DNR POLST form signed and on file, but Section A - neither Attempt Resuscitation/CPR or Do Not Attempt Resuscitation is checked. Patient #13:EMR Code Status is DNR. 12/11/23 DNR POLST form signed and on file, but Section A - neither Attempt Resuscitation/CPR or Do Not Attempt Resuscitation/DNR is checked.”

“Upon patient client record review, 8 of 14 (Patient #1, 6, 7, 8, 10, 11, 12, 13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: 10/15/25 MSW Visit note not authenticated with signature. Patient #6, 7, 8,10, 11, 12, 13: Patient Rights Form, Pg.2 of 7, includes name of a different hospice. The correct hospice is in the header of each page of the document. Patient #10: Initial CTI 6/22/25 states Coccyx ulcers are now healed. However, there is a documented order same date for referral to wound specialist to evaluate and treat. Interview with Admin/DPCS clarifies that part of previously existing wound is healed, but there is new breakdown same area. Also, 7/3/25 LVN note says Continuous Nursing Care remains in place due to recent decline in condition. Upon interview with Admin/DPCS, the patient was not on continuous care at that time. Continuous Care was actually initiated 7/16/25.”

“Upon review of policy and procedure, Policy #5-14.1 Retention of Records, did not include that if the hospice discontinues operation, hospice policies and procedures must provide for retention and storage of clinical records. The hospice must inform its State Agency and its CMS Regional Office where such clinical records will be stored and how they may be accessed. Review of Agency’s Policy #5-14.1 Retention of Records (also identified as Contingency Plan Policy in Table of Contents) does include that in the event hospice should cease operation, all clinical records, administrative and financial files will be sent and stored at another designated location. It does not specify responsibility to notify State Agency and CMS Regional Office regarding location and contact information for individual with responsibility.”