Summer Breeze Healthcare

“Upon patient record review, 3 of 14 (Patients #1, 2, 10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1, 2, 10: The patient/caregiver signed consents upon admission stating they chose the hospice medical director. The doctors name was printed onto the signed consents. He left the agency in April 2025, and the new medical director was contracted. This new medical director became the attending, however, there was no evidence of documentation of discussion with the family, and no evidence of a change in physician consent or form completed with patient or family.”

“Upon patient record review, 10 of 14(Patients #1, 2, 3, 4, 5, 6, 7, 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 Patients #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting. In addition, these patients were provided with oxygen. Oxygen is not on the medication profile.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a Registered Nurse is 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 #1: The patient medication order reads, “Volsartan 80mg. One tablet every morning at 8am. Hold medication if systolic BP is less than 120.” During RN visits on 07/07/25, 07/14/25, 07/23/25/ 08/04/25, 08/11/25, and 09/03/25, systolic blood pressure readings were below 120. There was no evidence that the RN notified the physician for further orders or changes to the plan of care””

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #1: The patient medication order reads, “Volsartan 80mg. One tablet every morning at 8am. Hold medication if systolic BP is less than 120.” During RN visits on 07/07/25, 07/14/25, 07/23/25/ 08/04/25, 08/11/25, and 09/03/25, systolic blood pressure readings were below 120. There was no evidence of the nurse educating the family to hold the medication.”

“Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1,3,6: The patient sees the hospice spiritual care. There is no evidence of interventions or goals for spiritual care on the plan of care. The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #2,4,7,8,9,10: The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #5: The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. The patient has history of epileptic seizures and is prescribed Depakote. There is no evidence of interventions or goals for seizures.”

“Upon patient record review, 2 of 14 (Patients #4, 6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4 and 6: The patient has spiritual care. The order, however, reads initial visit then prn. PRN visits cannot stand alone.”

“Upon patient record review 2 of 14 (Patients #3, 6) did not have evidence documentation in the patient record 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 #3: In the record, the hospice aide began seeing patient on 07/30/25. The RN did a supervised visit on 08/08/25. The hospice aide continues to see patient, however, there is no evidence of an RN supervised visit since 08/08/25, which was 25 days ago. Patient #6: In the record, the hospice aide began seeing the patient on 07/30/25. A supervised visit was completed by the RN on 08/12/25 and 08/18/25. There is no evidence of further RN supervision which is now 17 days.”