Every finding on record at Bright Source Hospice LLC

Upon patient record review, 3 of 14 (Patient #1,6,8) 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-Order dated 9/18/24 for Lidocaine 4% patch does not indicate specific location to apply patch on the medication profile. Order dated 9/8/24 for A&D ointment does not indicate specific location on medication profile. Orders dated 1/28/25 for Acetaminophen 500mg tab 1 tab Q4 PRN and order dated 11/25/24 for Acetaminophen 650mg RS 1 Q4 PRN exceed 4000mg daily amount, no evidence of maximum allowable on medication profile. Corrected on site. Patient #6-Order dated 4/5/25 for Oxygen Concentrator DME, however no evidence of oxygen administration orders on medication profile. Patient #8-Orders dated 3/17/25 for Norco 5/325mg 1 tab Q6 PRN and Acetaminophen 650mg RS 1 Q4 PRN exceed 4000mg daily amount, no evidence of maximum allowable on medication profile. Order dated 3/27/25 for 10L Oxygen Concentrator DME, however no evidence of oxygen administration orders on medication profile. Corrected on site.

Upon patient record review, 5 of 14 (Patient #1,2,3,7,10) 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 #1,2,3,7,10-No evidence of initial bereavement assessment completed within 5 days of SOC.

Upon patient record review, 2 of 14 (Patient #3,6) 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 #3-Order dated 2/18/25 for wound care orders, SN visit 4/1/25 narrative states "No signs of skin breakdown" and SN visits completed 4/2/25 and 4/7/25 however no evidence of wound care or measurements completed. Patient #6-MD narrative states patient with Stage 3 sacral wound and blisters to legs and hip with a discussion with wound care team, no evidence of assessment by RN.

Upon patient record review, 1 of 14 (Patient #8) 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 #8-Patient with medication orders for Eliquis daily, no bleeding precautions in place. Corrected on site.

Upon patient record review, 3 of 14 (Patient #1,6,8) 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-Order dated 9/18/24 for Lidocaine 4% patch does not indicate specific location to apply patch.. Order dated 9/8/24 for A&D ointment does not indicate specific location. Orders dated 1/28/25 for Acetaminophen 500mg tab 1 tab Q4 PRN and order dated 11/25/24 for Acetaminophen 650mg RS 1 Q4 PRN exceed 4000mg daily amount, no evidence of maximum allowable. Corrected on site. Patient #6-Order dated 4/5/25 for Oxygen Concentrator DME, however no evidence of oxygen administration orders. MD narrative states patient has Stage 3 sacral wound and blisters to legs and hip, no evidence of wound care orders or follow up. Patient #8-Orders dated 3/17/25 for Norco 5/325mg 1 tab Q6 PRN and Acetaminophen 650mg RS 1 Q4 PRN exceed 4000mg daily amount, no evidence of maximum allowable. Order dated 3/27/25 for 10L Oxygen Concentrator DME, however no evidence of oxygen administration orders. Corrected on site.

Upon patient record review, 1 of 14 (Patient #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 #6-MD narrative upon SOC 4/5/25 states patient with Stage 3 sacral wound and blisters to legs and hip with a discussion with wound care team, no evidence of discussion outcome or update to plan of care.

Upon client record review, 5 of 14 (Patient #3,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3-Order dated 2/18/25 for SN frequency 2x/week, Order dated 3/22/25 for SN frequency 3x/week. Duplicate SN frequency orders. Corrected on site. Order dated for 2/18/25 for wound care orders, no evidence of wound care completed at subsequent SN visits. Patient #7-Order dated 4/1/25 contain duplicate orders for SN frequency, no evidence incorrect order being discontinued. Corrected on site. Patient #8- Order dated 3/26/25 for LVN visits 3x/week, no evidence of RN visit order frequency. RN supervisory visit completed 3/31/25. Corrected on site. Patient #9- Order dated 1/23/25 for MSW visit frequency for 1x/recert, visits completed 2/6/25, 3/28/25 and 4/1/25 with no orders for visits. Corrected on site. Patient #10 Orders dated 2/1/25 for LVN visit frequency 1x/week, RN supervisory visits completed 4/3/25, 3/30/25, 3/14/25, 3/2/25 and 2/26/25, no evidence of orders for RN visits. Corrected on site.SN visit completed 3/18/25 include notation of 3 wound treatments completed, no evidence of wound care orders. Corrected on site.

Upon patient record review 1 of 14 (Patient #1) 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 #1 Aide visits completed 3/26/25, 3/24/25, 3/21/25, 3/18/25, 3/15/25 and 3/1/25 documented the task for Bowel Movement completed, no evidence of task on aide care plan. Aide visits completed 3/26/25 and 3/24/25 documented the task for Vitals obtained, no evidence of task on aide care plan.

Upon patient record review 1 of 14 (Patient #1) 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 #1 9/13/24 order frequency for aide visits 3x/week, no evidence of aide supervisory visits completed since 9/13/2024 Corrected on site.

Upon patient client record review, 1 of 14 (Patient #10) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #10 SN visit completed 3/18/25 include notation of 3 wound treatments completed, no evidence of how patient tolerated wound treatment.

Upon patient client record review, 1 of 14 (Patient #10) 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 #10 SN visit completed 3/18/25 include notation of 3 wound treatments completed, no evidence of details of wound care/treatment.