Every finding on record at Blue Monarch Hospice LLC

Upon patient record review 2 of 14 (Patient #1, #2) 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: The patient was admitted on 3/18/24. There is not evidence the psychosocial assessment was completed until 3/25/24 which is greater that the 5 day requirement. Patient #2: The patient was admitted on 1/31/24. There is not evidence the psychosocial assessment was completed until 2/6/24 which is greater that the 5 day requirement.

Upon patient record review, 6 of 14 (Patient #3, #6, #7, #9, #8, #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 #3: The medication record indicates Nitroglycerine 0.4 mg every 5 minutes as needed. Note: may give 3 doses. There are no directions after 3 doses. (Corrected on site) Patient #6: The medication record indicates an order on 5/20/24 for Oxygen continuous 3-4L/min via NC. On 6/7/24 the vital signs indicate Oxygen 2 L/min and does not indicate continuous or PRN. The same date the nurse's note indicates "he is on O2 continuous at 2.5 L/min. Patient #7: The medication record indicates an order on 3/29/24 Nystatin Powder to underarms for fungal infection, discontinue when resolved. There is no documentation found as to whether the infection is resolved. The Nystatin remains on the medication record. (Corrected on site.) Patient #8, the agency medication record did not list Morphine and Colace that was listed on the facility medication profile. In addition, the facility medication record did not list DuoNeb and Robitussin which were listed on the agency medication record. Patient #9: During the home visit, the patients care giver identified the patient visited a pain physician who prescribed a Prednisone pill pack for 7 days. The caregiver stated the medication ended on 6/17/24. The is no evidence of an order for Prednisone on the medication record. Patient #10: During the home visit, Morphine tablets on the medication sheet of the Agency and home, were not available in the home.

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 3/18/24. There is not evidence the bereavement assessment was completed until 3/25/24 which is greater that the 5 day requirement. Patient #2: The patient was admitted on 1/31/24. There is not evidence the bereavement assessment was completed until 2/6/24 which is greater that the 5 day requirement.

Upon patient record review, 3 of 14 (Patient #3, #6, #9) 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 #3: The order for Nitroglycerine 0.4 mg every 5 minutes as needed. Note: may give 3 doses. There are no directions after 3 doses. (Corrected on site) Patient #6: There is an order on 5/20/24 for Oxygen continuous 3-4L/min via NC. On 6/7/24 the vital signs indicate Oxygen 2 L/min and does not indicate continuous or PRN. The same date the nurse's note indicates "he is on O2 continuous at 2.5 L/min. Patient #8, the agency did not have order for Morphine and Colace that was listed on the facility medication profile. Patient #9: During the home visit, the patients care giver identified the patient visited a pain physician who prescribed a Prednisone pill pack for 7 days. The caregiver stated the medication ended on 6/17/24. The is no evidence of an order for Prednisone.

Upon patient record review, 3 of 14 (Patient #4, #5, #6) 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 #4: The record indicates an order on 6/8/24 for Wound to Left elbow to cleanse, pat dry, apply silver alginate, cover with dressing. The Plan of Care was not updated to include the wound. Patient #5: The record indicates an order on 4/27/24 for Nectar thick liquids for dysphagia. The Plan of Care was not updated to include dysphagia. (Corrected on site.) Patient #6: The medical record indicates an order on 3/29/24 Nystatin Powder to underarms for fungal infection, the Plan of Care was not updated for fungal rash. (Corrected on site.)

Upon observation, 1 of 3 home patients, (Patient #8), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #8: During the home visit, the RN did not follow acceptable bag technique as evidenced by not using a barrier, not separating clean/dirty, and re-entering bag several times to retrieve additional equipment.

Upon patient record review, 5 of 14 (Patient #2, #6, #7, #9, #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 #2: The mediation record indicates the patient is on Xarelto. Bleeding precautions is not on the HHA plan of care. (Corrected on site.) Patient #6: There is an on 5/20/24 for O2 continuous 3-4 L/min. The HHA plan of care was not updated and continues to indicate O2 2L PRN. (Corrected on site.) Patient #7: The medication record indicates the patient is on Eliquis. Bleeding precautions is not on the HHA plan of care. (Corrected on site.) Patient #9: The medication record indicates the patient is on Eliquis. Bleeding precautions is not on the HHA plan of care. (Corrected on site.) Patient #10: The Neurological POC indicates new onset of seizures and the patient is taking Keppra for seizures. Seizure precautions is not on the HHA plan of care. (Corrected on site.)

Upon patient record review 1 of 14 (Patient #10) 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 #10: The HHA plan of care indicates brush hair, shampoo, brush teeth, clean nails. On 6/7/24 and 6/11/24 the HHA did not complete the tasks.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency has a cost savings less than 5% for 2023

Upon contract review, 1 of 1 (Coastal Mobile) 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 personnel record review, 1 of 12 (Personnel #12 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. The OT has provided services to patients in the past 6 months. There is no evidence in the record of orientation to the hospice philosophy.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: There was not evidence in the record that all transfer documents were transferred to the receiving facility. There was a one page note on the discharge summary stating "all forms sent". However, in the area designated to check each document needed to be sent for a transfer, none of the boxes were checked.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #12: There is no evidence in the medical record that the discharge summary was sent to the attending physician after the patient revoked from hospice.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12: There is no evidence in the medical record that the discharge summary contained a summary of the patient's stay, the current plan of care, latest physician orders or other documentation that would assist in post-discharge continuity of care.

Upon SNF/NF contract review, 1 of 4 (Poway HC contract) did not have evidence the contract specifies the provision of hospice services in the facility and that the contract is signed by authorized representatives of the hospice and the SNF/NF or ICF/IID before the provision of hospice services.

Upon SNF/NF contract review, 1 of 1 (Poway HC) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies The SNF contract did not have a provision that the SNF immediately notifies hospice if: •A significant change in a patient's physical, mental, social or emotional status occurs •Clinical complications appear that suggest a need to alter the plan of care •When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions •A patient dies

Upon SNF/NF contract review, 1 of 1 (Poway HC) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.