Helpful Hospice Care

“Upon patient record review, 5 of 14 (Patient #1, 3, 4, 5, 8) did not contain evidence 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: Order date 01/16/26: Norco 5-325mg 1 tab every 4 hours as needed. Acetaminophen 325mg 2 tabs every 4 hours as needed. There was no maximum dose listed. Patient #3: Order date 01/09/26: Nystatin 100,000 units 3g “apply thin layer on affected area daily”. Triple Antibiotic 4g “apply thin layer on affected area daily and as needed”. There was no indication of area to apply. Patient #4: Order date 11/13/25: A&D ointment 3g “apply thin layer on affected area as needed”. Calmoseptine cream 3g “apply thin layer on affected area as needed”. There was no indication of area to apply. Patient #5: Order date 12/16/25: A&D ointment 4g “apply thin layer on affected area daily”. Calmoseptine 4g “apply thin layer on affected area daily”. Triple Antibiotic ointment “apply thin layer on affected area as needed”. Hydrocortisone Acetate 2% 3g “apply thin layer on affected area twice a day”. There was no indication of area to apply. Patient #8: Order date 08/04/25; Lacri-Lube eye ointment 6mm, once day. Systane 1 drop three times a day. Neither indicated which eye(s). A&D ointment “apply a thin layer on affected area daily as needed”. Calmoseptine “apply a thick layer on affected area daily as needed”. CBD4 Freeze Pump Max. “Strength” 4-1% 4g “apply a thin layer on affected area daily as needed”. There was no indication of area to apply.”

“Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that the comprehensive assessment included a bereavement component which included 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: Patient was admitted on 01/16/26 and there was no indication that a bereavement assessment was completed.”

“Upon patient record review, 3 of 14 (Patient #1,3,7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: The documentation in the record did not have evidence of an RN visit made for a comprehensive assessment or update every 15 days. Patient #3: The documentation in the record did not have evidence of an RN visit made for a comprehensive assessment or update every 15 days. The RN did not complete any visits since admission 12/12/25 to 1/11/26. Patient #7: The documentation in the record did not have evidence of an RN visit made for a comprehensive assessment or update. The only RN visits performed was on admission and 9/15/25.”

“Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #7: The 08/28/25 admission assessment by the RN stated: “Patient had wound on back of their head and had minor bleeding caused by fall. Wound care was performed. Wound was washed with Normal Saline 0.9%, pat dried, triple antibiotic was applied and wound was wrapped with kerlix”. The next RN visit note on 09/15/25: “no skin issues reported or seen during this visit”. The LVN then visited this patient on 09/20/25 and 09/27/25 documenting that this patient continued to have a wound and that wound care was performed. The LVN note on 10/04/25 indicated that wound was healed documenting “skin intact”. There is no evidence from 8/28/25 to 10/4/25 that the wound was assessed.”

“Upon patient record review, 4 of 14 (Patient #1, 2, 4, 5) did not contain evidence that the hospice had 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: The Initial POC/all updated indicated that the patient was a DNR. The Advance Directive attached to the chart indicated that the patient had elected to be Full Code requesting CPR to be performed. Patient #2: Patient was admitted on 12/26/25 and all nursing interventions/goals are indicated to have been completed. Patient #4: The California POLST was attached to the chart but the POC listed patient as being a DNR status. Patient #5: Patient was admitted on 11/02/25 and all nursing interventions/goals are indicated to have been completed.”

“Upon patient record review, 5 of 14 (Patient #1, 3, 4, 5, 8) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Initial POC: Norco 5-325mg 1 tab every 4 hours as needed. Acetaminophen 325mg 2 tabs every 4 hours as needed. There was no maximum dose listed. Patient #3: Initial POC/all updated: Nystatin 100,000 units 3g “apply thin layer on affected area daily”. Triple Antibiotic 4g “apply thin layer on affected area daily and as needed”. There was no indication of area to apply. Patient #4: Updated POC and all following after order date 11/13/25: A&D ointment 3g “apply thin layer on affected area as needed”. Calmoseptine cream 3g “apply thin layer on affected area as needed”. There was no indication of area to apply. Patient #5: Updated POC and all following after order date 12/16/25: A&D ointment 4g “apply thin layer on affected area daily”. Calmoseptine 4g “apply thin layer on affected area daily”. Triple Antibiotic ointment “apply thin layer on affected area as needed”. Hydrocortisone Acetate 2% 3g “apply thin layer on affected area twice a day”. There was no indication of area to apply. Patient #8: 10/23/25 order stated foley 16fr, this is an incomplete order as it does not contain balloon size, flush orders or frequency for changing. In addition, the initial POC/all updated: Lacri-Lube eye ointment 6mm, once a day. Systane 1 drop three times a day. Neither indicated which eye(s). A&D ointment “apply a thin layer on affected area daily as needed”. Calmoseptine “apply a thick layer on affected area daily as needed”. CBD4 Freeze Pump Max. “Strength” 4-1% 4g “apply a thin layer on affected area daily as needed”. There was no indication of area to apply.”

“Upon patient record review, 3 of 14 (Patient #6, 7, 9) did not contain evidence that a revised plan of care included information from the patient’s updated comprehensive assessment and noted the patient’s progress towards outcome/goals from the plan of care. Patient #6: Patient in the second certification period and all nursing interventions/goals are indicated to have been completed. Patient #7: Patient in the second certification period and all nursing interventions/goals are indicated to have been completed. Patient #9: Patient in the seventh certification period and all nursing interventions/goals are indicated to have been completed.”

“Upon client record review, 9 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9) did not contain evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #1: The RN admission narrative on 01/16/26 stated; “patient presents with Stage 1 pressure injury on sacral area; Stage 2 pressure ulcers on both left and right buttocks; multiple abrasions on BLE and multiple skin tears on BUE s/p fall. Proper skin care and inspection done and discussed to PCG”. Per LVN note 01/21/26 indicated in the Skin Care Provided section under skin assessment was scored as Moderate (4-6). There was no indication of orders being obtained for the skin/wound care. Patient #2: Initial POC indicated SN visits 1x/weekly: weeks of 01/11/26, 01/18/26 and 01/25/26 all noted two visits were made. Patient #3: Initial POC and updates indicated SN visits 1x/weekly: weeks of 12/14/25, 12/28/25 and 01/18/26 all noted two visits were made. Week of 01/11/26 noted three visits were made. Patient record indicated a wound to left great toe being noted from day of admission to current date. Per RN admission narrative 12/12/25: “continue to do current treatment until obtain an official order from MD. Blanchable redness on and off on coccyx area. Cleansed affected area with NS, pat dry, apply Honeycomb cream cover with dry dressing and secured with tape”. There are no orders for this or either wound. Per LVN note 12/28/25 indicated wound to left great toe and 1st toe and wound care as follows: “wound is red with minimal drainage, treatment on going, responding slowly”. Per LVN note 12/30/25: “I assess her Left toe and looks normal wound dressing was changed.” Per LVN note 01/04/26: “patient continue to have wound on her left toe, wound care was performed”. Per LVN note 01/12/26: “wound care was done to her left 2nd toe”. Per LVN note 01/24/26: “patient continues to have wound on her left toe, wound care was performed”. Per LVN note 01/26/26: “I visit patient because she complain of foot pain. I assess patient foot she still has wound on 2nd toe from Nail pressure of first toe. Podiatry visit was requested”. There was no wound orders obtained for these wounds. Patient #4: Initial POC and updates indicated SN visits 1x/weekly: weeks of 11/16/25, 11/30/25, 12/14/25, 12/28/25, 01/11/26 and 01/25/26 all noted two visits were made. Patient #5: Initial POC and updates indicated SN visits 1x/weekly: weeks of 11/16/25, 11/30/25, 12/14/25 and 12/28/25 all noted two visits were made. Patient #6: Initial POC and updates indicated SN visits 2x/weekly: weeks of 10/05/25, 11/02/25, 11/17/25, 12/14/25, 12/28/25 and 01/11/26 all noted one visit was made. Week of 10/12/25 noted three visits were made. Patient #7: Initial POC and updates indicated SN visit 1x/weekly: Weeks of 09/14/25, 09/28/25, 10/12/25, 10/26/25, 11/24/25 and 12/07/25 all noted two visits were made. Weeks of 12/28/25 and 01/11/26 there was no indication of visits being made. Per 08/28/25 admission assessment by RN: “Patient had wound on back of their head and had minor bleeding caused by fall. Wound care was performed. Wound was washed with Normal Saline 0.9%, pat dry, triple antibiotic was applied and wound was wrapped with kerlix”. Per LVN note 08/30/25: “wound is present, care provided”. Per LVN note 09/06/25: “Patient has wound on the back of the head. Educated patient/PCG and family on skin impairment and treatment of current wound.” Per LVN note 09/13/25: “SN instructed to always assess wound dry sterile dressing when removed for any symptoms/signs of infection, such as increased drainage amount, any odor, drainage color, etc.” Per RN note 09/15/25: “no skin issues reported or seen during this visit”. Per LVN note 09/20/25: “wound is present. Instructed Pt/caregiver to clean the wound with saline before each application and use clean hands or a sterile tool to apply the ointment.” Per LVN note 09/27/25: “Wound care was performed. Wound was washed with Normal Saline 0.9%, pat dried. Triple antibiotic was applied and wound was wrapped with kerlix. Proper skin care and inspection done and discussed to patient/PCG”. There was no wound orders obtained for these wounds. Patient #8: 10/23/25 order, foley 16fr - Per LVN note 10/23/25; “foley administration during nursing visit because of urine retention caused by UTI’s”. There was no further mention of foley until visit by LVN on 11/22/25 stating “Patient bladder is incontinent, she continues to have catheter in place she will have catheter removed November 26”. Next LVN note 11/29/25 states “Patient is bladder incontinent. Catheter was removed today successfully”. There was no order for removal. Patient #9: SN visit frequency from initial POC lists 1x/week: the weeks of 08/10/25, 08/24, 09/07, 10/05, 10/29, 11/02, 11/16, 11/30, 12/14, 01/11/26 and 01/18 all had two visits noted each week.”

“Upon patient record review 2 of 14 (Patient #4, 8) did not contain evidence that the IDG ensured that the care and services provided were based on all assessments of the patient and family needs. Patient #4: MSW initial assessment narrative on 11/07/25 stated “Patient has final arrangements complete. Daughter didn’t have the information on hand. Social Work will follow up. Social worker will inform IDT and will continue with monthly visits”. There were no further visits made. The current orders do not meet the patient needs. Patient #8: MSW initial assessment narrative on 08/07/25 stated “Social worker will follow up with final arrangements”. There were two additional visits made for recertification assessments, on 10/15/25 and 12/15/25, and neither one mentioned this being followed up on.”

“Upon patient record review, 2 of 14 (Patient #3, 7) did not contain evidence that the IDG documented the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #3: Per 12/12/25 admission assessment by RN: Left great toe and 1st toe wound “continue to do do current treatment until obtain and official order from MD. Blanchable redness on and off on coccyx area. Cleaned with NS, pat dry, apply Honeycomb cream cover with dry dressing and secured with tape”. There was no indication that MD was made aware of these wounds. Patient #7: Per 08/28/25 admission assessment by RN: “Patient had wound on back of their head and had minor bleeding caused by fall. Wound care was performed. Wound was washed with Normal Saline 0.9%, pat dry, triple antibiotic was applied and wound was wrapped with kerlix”. There was no indication that MD was made aware of this wound.”

“Upon patient record review, 1 of 14 (Patient #8) did not contain evidence that the hospice aide assignments and duties were: • 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 #8: Patient had foley catheter placed on 10/23/25 but aide POC was not updated to reflect this.”

“Upon patient record review 4 of 14 (Patient #1, 3, 4, 6) did not contain evidence of documentation in the patient record that a hospice aide provided services that were: • 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: IDG ordered for aide to make 2x/weekly visits: There was no aide POC/assignment sheet completed by the RN and there were no visits made for this patient. Patient #3: Aide POC/IDG indicated nails to be cleaned at every visit and this was not done during home visit. Lotion was indicated to be applied at every visit and this was not done during home visit. ROM Active-Passive exercises were indicated to be completed at every visit and this was not done. Peri-care was not indicated on the POC but the aide did this during home visit. Patient #4: Aide POC/IDG indicated 2x/weekly visits: week of 01/18/26 there was only one visit made and no further visits have been made since 01/19/26. The POC/IDG also indicated for vitals to be checked at every visit and there was no indication that vitals were completed during any visits made. Patient #6: Aide POC/IDG indicated 2x/weekly visits: week of 01/18/26 there was only one visit made. The POC/IDG also indicated for vitals and date of bowel movement to be obtained at each visit and there was no indication that either were completed during any visits made. During visits on 10/07/25 and 10/10/25 the “Feeding” section was left blank by the aide and RN indicated for diet as tolerated, NAS/NCS and aspiration precautions for each visit.”

“Upon patient record review 1 of 14 (Patient #8) did not contain evidence 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 #8: Aide started making visits on 08/04/25 with the first supervisory visit being completed on 08/26/25. The next one was completed on 09/15/25. All supervisory visits were completed in timely manner following 09/15/25 until 12/22/25, with this being the last one completed. Aide visits have continued to be made through week of survey.”

“Upon patient client record review, 4 of 14 (Patient #3, 5, 7, 8) did not contain evidence that all entries were 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 #3: LVN visit note dated 01/12/26 was not signed/dated. RN visit note dated 01/14/26 was not signed dated. In addition, the patient record indicated a wound to left great toe being noted from day of admission to current date. Per RN admission narrative 12/12/25: “continue to do current treatment until obtain an official order from MD. Blanchable redness on and off on coccyx area. Cleansed affected area with NS, pat dry, apply Honeycomb cream cover with dry dressing and secured with tape”. It is unclear what area this wound dressing was applied to. Per LVN notes 12/17/25 and 12/20/25 they did not mention any wound(s). Per LVN note 12/27/25: “has wound - Patient continues to have wound on her Left toe wound care was performed”. Per LVN note 12/28/25 indicated wound to left great toe and 1st toe and wound care as follows: “wound is red with minimal drainage, treatment on going, responding slowly”. Per LVN note 12/30/25: “I assess her Left toe and looks normal wound dressing was changed.” Per LVN note 01/04/26: “patient continue to have wound on her left toe, wound care was performed”. Per RN note 01/11/26: “Left great toe against first toe wound redness with excessive drainage, treatment in progress responding well”. Per LVN note 01/12/26: “wound care was done to her left 2nd toe”. Per LVN note 01/19/26 it did not mention any wound(s). Per LVN note 01/24/26: “patient continues to have wound on her left toe, wound care was performed”. Per LVN note 01/26/26: “I visit patient because she complain of foot pain. I assess patient foot she still has wound on 2nd toe from nail pressure of first toe. Podiatry visit was requested”. There was no evidence of complete documentation of wound care that was being performed. Patient #5: LVN visit note dated 11/04/25 was not signed/dated. Patient #7: Per LVN note 08/30/25: “wound is present, care provided”. Per LVN note 09/06/25: “Patient has wound on the back of the head. Educated patient/PCG and family on skin impairment and treatment of current wound.” Per LVN note 09/13/25: “SN instructed to always assess wound dry sterile dressing when removed for any symptoms/signs of infection, such as increased drainage amount, any odor, drainage color, etc.” Per RN note 09/15/25: “no skin issues reported or seen during this visit”. Per LVN note 09/20/25: “wound is present. Instructed Pt/caregiver to clean the wound with saline before each application and use clean hands or a sterile tool to apply the ointment.” There was no evidence of complete documentation of wound care that was being performed. Patient #8: SC recertification note dated 12/15/25 was not fully completed and also lacked a signature/date.”