Every finding on record at Calstro Hospice, Inc

Upon patient record review 1 of 20 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: Patient declined spiritual counselor service. No documented evidence spiritual assessment performed.

Upon patient record review, 1 of 20 (Patient #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 #10: During patient visit, noted discrepancies between SNF med profile and hospice med profile. SNF profile includes patient med dosages: Fentanyl Patch (1) 100 mcg/hr. patch and (1) 25 mcg/hr. patch beginning 1/17/26. Hospice has Fentanyl 150 mcg (1) patch transdermal every 72 hrs. effective 1/18/26. SNF med profile has 1/16/26 Hydromorphone 1mg/ml (4) ml q2hrs PRN. Hospice med profile has 1/18/26 (6) ml q 2 hrs. prn. (Hospice staff followed up with facility to reconcile upon discussion.)

Upon patient record review, 3 of 20 (Patient #1, 7, 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: Admitted with Xarelto and Eliquis. IDG Care Plan did not include problems, goals interventions related to bleeding precautions initially. (Med discontinued 1/16 and 1/15/26). Also, patient has Keppra prescribed for seizures with no problems, goals, interventions related to seizure precautions. Patient #7: Patient admitted with Keppra prescribed for seizures,with no problems, goals, interventions related to seizure precautions. Patient #10: Patient has multiple meds prescribed for seizures with no problems, goals, interventions related to seizure precautions.

Upon patient record review, 2 of 20 (Patient #4, 9) 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: Patient admitted with order for oxygen 15 lpm per Oximyzer continuously. IDG problems, goals interventions for respiratory problem, show oxygen at 2lpm. and does not specify rate of prn or continuous. 1/2/26 order to decrease to 4lpm, but no update to flow rate at that time. Patient #9: Patient admitted with fungating tumor of chest. Orders for change in wound treatment 1/7/26 Xeroform to CA Alginate with no update to problems, goals and interventions through 1/20/26 IDG. Updated prior to end of survey.

Upon client record review, 3 of 20 (Patient #2, 4, 17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: 12/13/25 Physician order: May have volunteer evaluation. No documented evidence services provided or declined. Patient #4: 12/14/25 Physician order: May have volunteer evaluation. No documented evidence services provided or declined. Patient # 17: Patient order for oxygen 2lpm via NC. 2/3/25, day of patient death, oxygen was increased by hospice nurse to 5lpm via nasal cannula related to dyspnea, but nurse failed to document order for increase.

Upon patient record review, 6 of 20 (Patient #1, 2, 4, 7, 8,10) 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: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Xarelto and Eliquis prescribed with no bleeding precautions. Keppra prescribed with no seizure precaution addressed in Aide Care Plan. Patient #2: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Patient#4: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Rate was initially 15 lpm via Oxymizer continuously for sob. 1/2/26 order to decrease to 4 lpm with no update to Aide Care Plan. Patient prescribed Xarelto with no bleeding precaution addressed in Aide Care Plan. Patient t#7: Keppra prescribed with no seizure precautions addressed in Aide Care Plan. Patient #8: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Eliquis prescribed with no bleeding precautions addressed in Aide Care Plan. Patient #10: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Patient has multiple seizure medications prescribed with no seizure precautions addressed in Aide Care Plan.

Upon patient client record review, 1 of 20 (Patient #16) did not evidence that each patient record contains physician orders. Patient #16: Discharged for extended prognosis, with no documented evidence of physician order prior to discharge 12/20/25.

Upon patient client record review, 2 of 20 (Patient #14, 20) 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. Patient #14: 12/23/25 visit SN removed and replaced Foley catheter. The nurse did not document details including if/how much balloon deflated prior to removal and did not document details of prep/insertion/size of catheter or balloon. Patient #20: Contracted staff providing continuous care, BS, LVN signature not legible and typed name is first name only.

Upon client record review, 2 of 20 (Patient #15, 16) did not have evidence that the discharge summary includes all required information Patients #15: No evidence info sent to hospital where patient admitted, to facilitate continuity of care. Patient #16: No evidence info sent to attending MD to assist in post discharge continuity of care.

Upon patient record review, 2 of 5 (Patients #2 and 3) did not contain evidence that all entries were clear and complete: Patient #2: SOC 07/12/25. This documentation noted that the patient had a deep tissue injury (DTI) to the 'right' heel, with accompanying orders for wound care. The LVN made a follow-up visit on 07/13/25, and documented this DTI to be located on the 'left' heel. This is unclear documentation. Patient #3: SOC 07/14/25. The record noted that the patient had a left lateral, anterior head hematoma with abrasion, with accompanying orders for daily wound care, and daily use of ice packs. An LVN made a follow-up visit on 07/15/25. The documentation noted the presence, and observation, of this injury site. However, there was no documented description of the site status.

Condition of participation: Initial and Comprehensive assessment of the patient The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) 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,#2,#3,#4,#5,#6,#7: There is no evidence of drug review being performed by RN prior to LVN visit.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) 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,#2,#3,#4,#5,#6,#7:The record indicates LVN made visit in which vital signs were taken, questions asked regarding pain, and regarding if any respiratory issues. There is no evidence of any problems, goals, and to any patient issues in place for prior to LVN visit. Patient#2: The LVN indicates in documentation for tuck in visit on 12/6/24 that patient was experiencing dyspnea and obtained an order for oxygen 3lpm via NC continuous. Prior to RN initial assessment, LVN made a second visit on 2/7 during which LVN documents patient experiencing dyspnea and discomfort. LVN obtained order for additional dose of morphine. The hospice MD then came to facility during this visit and gave an order for facility to give Morphine every 2 hours as needed. There is no evidence of problems, goals, and interventions related to pain or respiratory needs. Patient#4: Per LVN documentation for "tuck in" visit 1/29, the LVN performed wound care cleaning an open wound on coccyx with normal saline, patting dry, and covering with silicone dressing. Documentation for the 1/29 LVN visit also indicates LVN emptied the ileostomy bag. There is no evidence of problems, goals, and interventions related to these needs. Patient#6: The LVN indicates during tuck in visit on 2/3/25 that patient was short of breathe. This was resolved with use of oxygen. There is no evidence of problems, goals, and interventions related to these needs.

Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) 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 #1,#2,#3,#4,#5,#6,#7: The record indicates the order for the LVN visit states "SN x 1 for wellness". However, this order is not specific to the scope of care for the visit.

Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) 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,#2,#3,#4,#5,#6,#7: There is no evidence of an order for LVN to perform vital signs, check pain status or if SOB.

Upon client record review, 3 of 7 (Patient #4,#6,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4,#6,#7: The record indicates LVN made "tuck in" visit at which the LVN completed vital signs, checked for pain and for SOB. There is no evidence of an order of plan of care related to this care. Patient#4: The record indicates LVN made "tuck in" visit at which the LVN completed care to an open wound and emptied ileostomy bag. There is no evidence of an order of plan of care related to these needs.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence the governing body/Administrator is providing oversight of the management of the hospice as evidenced by the agency not following §418.54 Condition of participation: Initial and comprehensive assessment of the patient, § 418.56 Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. Patients were being seen by an LVN and providing hands on care/assessment prior to the RN completing an initial assessment and developing a plan of care.

Condition of participation: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID.

Upon client record review, 4 of 7 (Patient #1,#2,#3,#5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1,#2,#3,#5: The record indicates LVN made "tuck in" visit at which the LVN completed vital signs, checked for pain and for SOB. There is no evidence of an order of plan of care related to this care.

Upon client record review, 4 of 7 (Patient #1,#2,#3,#5) did not have evidence that any changes in the hospice plan of care were discussed with the patient/family and SNF/NF or ICF/IID representatives, and are approved by the hospice before implementation. Patient #1,#2,#3,#5: There is no evidence of of plan of care being discussed with patient/family and the facility, or being approved before implementation or LVN visit being made. Patient#3: LVN visited for "tuck in" 4/22/24 at 630pm. A second LVN made death visit 4/22 at 2300. There is no evidence of a plan of care in place prior to passing of the patient.

Upon patient record review, 2 of 13 (Patient #1, 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 Patient 1: The medication list indicates Miralax powder 17g 1 scoop po daily. There are no instructions for reconstitution of this powdered medication. (corrected onsite) Patient 8: The medication list indicates hydrocortisone ointment 1% topical bid itching. There is no indication of an application site for this topical medication. (corrected onsite)

Upon patient record review, 1 of 13 (Patient #3) 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 3: On the initial comprehensive assessment, constipation was noted to be a concern for the patient. The medication list indicates the patient utilizes lactulose, senna, and Miralax to manage symptoms. The patient also uses a hemorrhoid cream. Additionally, the patient utilizes po pain medications which may contribute to constipation/decreased bowel motility. The patient required PRN SN visits on 12.27.2022 and 01.01.2023 for mechanical disimpaction. However, a care plan related to GI management/constipation has not been developed at any time for this patient. (corrected onsite)

Upon patient record review, 2 of 13 (Patient #1, 7) 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 1: Following the initial comprehensive assessment, ongoing visit orders for the chaplain were established for 3 PRN visits only. (corrected onsite) Patient 7: Following the initial comprehensive assessment, ongoing visit orders for the chaplain were established as will visit as needed per patient and family request. (corrected onsite)

Upon patient record review and observation, 1 of 13 (Patient #1) 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 equipment and supply needs. Patient 1: Per the comprehensive initial assessment, medication summary, and on direct observation during the home visit, the patient utilizes a hospital bed, oxygen equipment, a gerichair, a suction machine, and a nebulizer to manage the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite)

Upon patient record review, 12 of 13 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13) did not have evidence in the patient record that hospice aide assignments and duties are: • 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, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13: The hospice aide care plans, for tasks such as the patient's bath, hair care, and brushing the teeth, did not specify the frequency for the tasks ordered/being performed. (corrected onsite for all active patients)