Every finding on record at Compassionate Care Hospice LLC

Upon patient record review, 2 of 19 (Patient #2,5) 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 #2 - The medication profile listed Miralax 17gm daily for constipation. There was no evidence of a diluent added. This was corrected onsite. Patient #5 - The medication profile contained a section to designate who will administer the medications to the patient. The profile contained a key utilizing numbers as to who would administer these medications. The profile listed "3&4" which according to the key included "fam & hospice nurse". The profile did not include the facility nurse as a designated medication administrator.

Upon patient record review, 5 of 19 (Patient #6,8,9,11,14) 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 #6 - The medication profile listed ASA daily as a blood thinner. There were no problems, goals, or interventions listed related to bleeding risk. This was corrected onsite. Patient #8 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia. Patient #9 - The plan of care included an order for pureed food and thickened liquids. There were no problems, goals, or interventions listed related to dysphagia. Patient #11 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia. Patient #14 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia.

Upon patient record review, 1 of 19 (Patient #2) 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 #2 - The medical record included an order for Miralax 17gm daily for constipation. There was no evidence of a diluent added.

Upon patient client record review, 1 of 19 (Patient #13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #13 - The admission agreement which included the election of benefit on page 3 of 5, included a section "I choose to elect the Medicare hospice benefit from Compassionate Care Hospice starting on _______." This start of care date was left blank.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #5 - The plan of care did not include who was responsible for medication administration. The facility nurse was not included as a designated medication administrator.

Based on record review and staff interviews, the hospice failed to ensure the completion of the clinical record to reflect the family member’s concern regarding a change in the patient’s condition for one of three sampled patients (Patient 1).  This failure created the potential for not having the patient's current condition to provide necessary care and services for this patient. --- Clinical record review for Patient 1 was initiated on 11/24/25.  The clinical record showed Patient 1's SOC was 8/31/25.   Patient 1 was certified for home health services during the certification period from 8/31/25 to 11/28/25.The Report of Death and Disposal of Controlled Drug showed the hospice received a call on 9/22/25 at 0200 hours, and the date and time pronounced death was 9/22/25 at 0240 hours.  Further review of the clinical record showed no documented evidence of what happened prior to the patient's death, including the patient's change of condition and communication between the family and hospice or hospice nurse.Review of Patient 1’s Call Log dated 9/22/25, showed Patient 1’s family called the hospice at 0116 and 0127 hours.On 11/26/25 at 1420 hours, an interview was conducted with Family Member 2.  Family Member 2 stated around 0115 hours, the caregiver called and reported that the patient was making a loud rattling sound.  The caregiver contacted the hotline and was instructed to administer Levsin (medication to treat the excessive secretion) but was unable to locate the medication.  Later, around 0130 hours, Family Member 2 called and requesting for a nurse be sent immediately.  She was told to wait for the nurse’s visit the following morning, but she insisted that a nurse had to see Patient 1.On 12/1/25 at 1100 hours, an interview and record review were conducted with the DPCS and Administrator.  The DPCS was asked whether there was any documentation showing the family member had called around 0115 and 0130 hours.  The DPCS and Administrator were unable to provide such documentation; however, both stated they reviewed the call log and confirmed the phone calls from the family member were received at 0116 and 0127 hours.  The DPCS was also asked whether the nurse had documented any return call to the family informing them of the expected visit time. The DPCS and Administrator were unable to provide such documentation.  The DPCS stated the staff member who received the call should have documented in the communication log as part of the medical record.  Both the DPCS and Administrator verified these findings.Further review of the communication/progress log dated 9/22/25 at 0120 hours, showed a late entry by Receptionist 1 showing a call from the caregiver who reported that the patient had phlegm and was having difficulty breathing.  The caregiver requested for advise on how to proceed.  The SN advised elevating the patient’s head and increasing oxygen concentration.  The caregiver was also instructed to suction or perform an oral sweep to remove phlegm from the mouth.  The SN advised administering of Levsin; however, the caregiver reported no Levsin available at the bedside.  The office was notified to send a STAT refill request to the pharmacy.  The caregiver was also instructed to administer morphine to assist with breathing and DuoNeb (medication for opening airways and reducing respiratory inflammation) to help clear the airway. The SN confirmed the interventions and instructed the caregiver to call back if the patient’s condition changed.  The caregiver verbalized understanding.Further review of the communication/progress log dated 9/22/25 at 0127 hours, showed another late entry.  The patient’s daughter called and was informed that instructions had been provided to the caregiver regarding suctioning, repositioning, and medication administration, including removing phlegm from the patient’s mouth.  She was advised that the patient should start Levsin, DuoNeb, and morphine (opioid pain medication), and that oxygen should be increased to 5 liters.  It was explained that the caregiver had confirmed he would carry out the interventions and would call back if there was no improvement.  A STAT order for Levsin was also being sent, as the caregiver reported none was available at the bedside.On 12/1/25 at 1630 hours, an interview and record review were conducted with the DPCS and Administrator. The DPCS stated Receptionist 1 made the late entries for 9/22/25 at 0120 and 0127 hours, today (12/1/25), after the issue was brought to their attention.  The DPCS and Administrator verified these findings.

Based on staff interview and record review, the hospice failed to ensure the written addendum showing diagnoses and non-covered items was completed with the actual date completed/provided to the patient/family member for one of three sampled patients (Patient 1).  This failure had to potential for not having an accurate information on the patient's clinical record. --- According to CFR 418.24, (c), For hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement. The election statement addendum must include the following:(9), Name and signature of the individual (or representative) and date signed, along with a statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not the individual's (or representative's) agreement with the hospice's determinations.Clinical record review for Patient 1 was initiated on 11/24/25.  The clinical record showed Patient 1's SOC was 8/31/25.   Patient 1 was certified for home health services during the certification period from 8/31/25 to 11/28/25.Review of the Admission Consent Form dated 8/30/25, showed the section titled "Patient Notification of Hospice Non-covered Items, Services & Drugs"—which should list diagnoses related or unrelated to the terminal illness, items/services/drugs, and reasons for non-coverage was originally left blank, with Family Member 1 initialing the page.On 11/26/25 at 1420 hours, an interview was conducted with Family member 2.  Family member 2 stated they had expressed a concern about the blank section of the admission consent form.  Although they signed the paperwork, the hospice had later added the information after signing.Review of another copy of Admission Consent Form dated 8/30/25, showed the Patient Notification of Hospice Non-Covered Items, Services & Drugs page was  completed with diagnoses related to the terminal illness, diagnosis not related to terminal illness, and medications not related to the terminal illness and not covered.  However, these diagnoses and medications were added to the original form that was signed/initialed by Family Member 1 on 8/30/25, which was not the actual date when the family member was informed or acknowledged the diagnoses and non-covered medications.  On 12/3/25 at 1100 hours, an interview was conducted with the Administrator, DPCS, and Administrator’s designee.  The Administrator stated the admission consent form was provided electronically to the family on 8/30/25, and the family was informed that the "Patient Notification of Hospice Non-covered Items, Services & Drugs" page was blank but still needed to be signed.  The Administrator explained that the system required all pages to be signed in order to proceed and complete the form.  On 9/3/25, the completed admission consent form, with the "Patient Notification of Hospice Non-covered Items, Services & Drugs" section filled out was sent to the family.  When asked why the family was required to sign a blank form and whether any updates to the non-covered items, services, or drugs should have been signed after the form was completed, the Administrator acknowledged that there was a system issue with the clinical records.  The Administrator verified the above findings.

Upon patient record review, 2 of 5 (Patient #3 and #5) 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 Patient #3 and #5: Admission order for SC 1x and PRN. The PRN frequency was not quantified.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The POC listed Skilled Nursing visit frequency of 2 X's per week. For Benefit Week 12/25/22 there were no visits made by the SN.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patients 1, 7, 8 There is not evidence in the patient record that the appropriate party received information concerning its policies on advance directives, including description of the state law. The consent was not signed by the patient or appropriate representative per CA regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #1, 7, 8: There is not evidence in the patient record confirming that patient or appropriate representative received a copy of the Patient's Rights and Responsibilities as consent (including acknowledgement) was not signed by the patient or appropriate representative per CA regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #1, 7, 8: There is no evidence in the patient record that a state court has adjudged the patient incompetent, and an appropriate representative designated to exercise patient's rights according to state law was not identified. The consent was not signed by the patient or appropriate representative per CA regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Upon patient record review, 4 of 13 (Patient #1, 7, 8, 12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: RP MD is filled in as physician. However, there is no evidence that this was the patient's or appropriate representative's choice, in accordance with CA regulations. Agency Medical Director and RP MD, (not a hospice employee) signed hospice consents, including choice of physician. Patient #7, 8: Dr. NS is filled in as physician. However, there is no evidence that this was the patient's or appropriate representative's choice in accordance with CA regulations. The agency Medical Director and Medical Director Designee signed hospice consents, including choice of physician. Patient #12: Admitting paper work / consent/election form is blank in section designated to document patient's choice of physician, therefore, there is no evidence that the patient chose physician.

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence of the appropriate documentation for release of confidential information. Patient 1, 7, 8: The release of information forms are not signed by the appropriate representative according to California regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 1, 7, 8: There is not evidence in the patient record that the patient received information about the services covered as consent was not signed by the patient or appropriate representative per CA regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Upon patient record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1, 7, 8: There is not evidence in the patient record that patient received information about the scope of services hospice will provide, as consent was not signed by the patient or appropriate representative per CA regulations. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 (Patient #5) 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 #5: Patient SOC 8-30-22 RN comprehensive assessment documented presence of CVC Right upper chest with a thorough assessment of CVC. There was no further documentation regarding the CVC assessment until 9/25/22 when it was discontinued.

Upon patient record review, 1 of 13 (Patient #5) 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 #5: RN documented in 8/30/22 initial comprehensive assessment the presence of CVC Right upper chest with insertion date of 7/22/22. There were no problems, goals, interventions for the CVC it was discontinued 9/25/22.

Upon patient record review, 10 of 13 (Patient #3, 4, 5, 7, 8, 9, 10, 11, 12, 13) 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. Patients #3, 4, 5, 7, 8, 9, 11, 13 Admission order for MSW eval and prn for any psychosocial issues and SC eval and prn for any spiritual issues. PRN frequency was not quantified. Patient #10 Admission order for MSW 1x upon admission and prn and SC 1x upon admission and prn. PRN frequency was not quantified. Patient #12 Admission order for MSW 1/mo and prn. PRN frequency was not quantified.

Upon patient record review, 1 of 13 (Patient #3) 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 admission 9/14/22 order change Foley catheter 16fr 10cc every 6 weeks per patient request, done by a hospice nurse, if clogged or dislodged, call hospice. IDG POC 9/21/22 lists in interventions to change Foley monthly and prn and also says catheter to be changed as ordered. No evidence of clear orders/plan of care for frequency of catheter changes.

Upon patient record review, 1 of 13 (Patient #1) 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 #1: The Plan of Care includes goal to maintain optimal blood sugar management for patient comfort. However, there is no documentation of progress toward goals and outcomes.

Upon client record review, 7 of 7 applicable (Patient #3, 4, 5, 9, 11, 12, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: admitted 9/14/22 with order SC eval and prn. SC visit on 10/16/22 without an order. Patient #4: admitted 9/7/22 with order for MSW eval and prn. MSW revisited patient 10/9/22 without an order. Patient #5: admitted 8/30/22 with order for MSW eval and prn, and SC eval and prn. MSW visits on 9/9/22 and 10/13/22 and SC visits on 9/29/22 and 10/4/22 without an order. Patient #9: admitted 1/27/22 with orders for MSW eval and prn. MSW visits 4/18, 6/11 and 8/25 without an order. Patient #11: admitted 9/4/22 with orders for MSW eval and prn. MSW visit on 9/20/22 without an order. Patient #12: admitted 2/4/22 with orders for MSW 1/mo and prn. MSW visit on 2/23/22 and SC visit on 2/24/22 without an order . Patient #13: admitted 7/27/22 with orders for MSW 1x eval and prn and SC 1x eval and prn. MSW visits on 8/29/22, 9/23/22 and SC visits on 8/12/22 and 9/27/22 without an order.

Upon observation, there was not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3: At beginning of visit, Aide placed his bag in the cloth recliner seat, with no barrier, as opposed to a clean surface, per agency's Bag Technique Policy. He proceeded to restroom to wash his hands. He turned the bathroom sink faucet off with his bare hands, as opposed to using a paper towel, per the agency's handwashing competency. Patient #2: The LVN placed her nursing bag on cloth sofa adjacent to patient, as opposed to a clean surface, per agency's Bag Technique Policy.

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #5: The competency checklist used by the agency lists shampoo, and not specifically sink, tub, bed type shampoos, therefore, competency for all 3 shampoos is not confirmed. The checklist form was updated prior to end of survey.

Upon patient client record review, 5 of 13 (Patient #1, 5, 7, 8, 12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, 7, 8 There is not evidence of the notice of patient's rights acknowledgment and/or the election statement (included in agency consent form) complete and signed by the appropriate representative in accordance with California regulation. Patient 1 Agency Medical Director and another physician (not a hospice employee) signed hospice consents. Patient 7, 8 Agency Medical Director and Medical Director Designee signed hospice consents. Patient #5 The election of benefit statement has an effective start date of 9/30/22 typed in. There is a line drawn through the typed date and 8/30/22 is written beside it. It is unclear if the date change was made before or after patient signature. Patient #12 The effective start date for hospice services is left blank on the election of benefit.

Upon client record review, 1 of 4 applicable (Patient #10) did not have evidence that the discharge summary includes all required information. Patient #10: 9/19/22 MSW visit noted that patient changed CPR/DNR status and revoked hospice participation to seek more aggressive treatment options. DC Summary does not include the presence of current advance directive and end of life decisions.

Upon client record review, 3 of 13 (Patient #1, 7, 8) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients 1, 7, 8: Medical Director and Medical Director Designee acting as responsible party signed and are not the appropriate guardian.

Upon client record review, 3 of 6 applicable (Patient #7, 8, 10) 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 #7: admitted 8/26/22 with order for MSW eval and prn. MSW visit on 10/7/22 without an order. Patient #8: admitted 8/26/22 with order for MSW eval and prn and SC eval and prn. MSW visits on 9/17/22, 9/18/22, 10/10/22 and SC visits on 9/29, 10/4 without an order. Patient #10: admitted 9/9/22 with order for MSW 1x upon admission and prn and SC 1x upon admission and prn. MSW visit on 9/19/22 and SC visit on 9/16/22 without an order.