Every finding on record at Concierge Hospice and Palliative Care, LLC

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure to maintain complete and accurate records. On review of RRNHV#5 there was wound assessment documentation that was noted to be conflicting between the RN and LVN documentation. The RN documentation noted a progressive shrinking in size of the wound each visit until healed. The LVN documentation included the same measurements of 2 x 1.5 each visit. This observation was reviewed with the RN supervisor, LVN, and the CEO.

Observed in Record Review. In 6 of 7 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals based on problems identified in the comprehensive assessments and updated reassessments that were specific, measurable, and timebound. In review of the records there were examples of goals that were not specific, measurable and time-bound. Examples in RRHV#1 that were not specific, measurable and time-bound were The patient/family/caregiver will verbalize having elimination needs met at an acceptable level and The pt/pcg/family/patient will have an adequate diet and fluids as tolerated. In RRHV#2 examples of goals that were not time-bound were The pcg/family will verbalize/express understanding of medication/treatment orders and side effects and The patient/PCG will know how to use and store O2 properly and safely. In RRHV#3 an example that was not time-bound was PCG/family will verbalize appropriate maneuvers to prevent choking and aspiration: positioning the patient during feeding. Further examples can be found in RRNHV#5 as Patient will maintain systolic blood pressure within safe limits to reduce symptoms and fall risk. Further examples of goals that were not specific, measurable, or time-bound could be found in RRNHV#6 and RRNHV#7. These observations were reviewed with the CEO, Admin/PDCS Designee, and RN Supervisor.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 there was documentation of an episode of increased edema, cough, and adventitious breath sound with the addition of Lasix, and Promethazine/Codeine yet the treatment and change in patient condition was not reflected in the plan of care. This observation was reviewed with the CEO, RN Supervisor, and DPCS/Admin Designee.

Observed in Record Review. In 3 of 7 patient records reviewed, the organization failed to ensure the plan of care was revised based on information from the patient's updated comprehensive assessment that noted the patient's progress to goals and outcomes specified. On review of RRHV#2 there were goals established at start of care that specified a target date yet the goal remained without update IDT to IDT and Certification to Certification. An example was patient will verbalize or demonstrate understanding of medication regimen and importance of compliance (in)4 weeks. The goal was established in October 2025. In RRHV#1 an example was Patient will remain free of preventable discomfort and/or complications due to impaired mobility within the next 2 weeks and will re evaluate on the next IDT meeting the goal was established July 2025. In RRHV#3 an example was Patient will be able to rest comfortably without exhibiting signs and symptoms of agitation, sadness or restlessness within the next 14 days. The goal was established on admission in April 2025. These observations were reviewed with the CEO, DPCS/Admin Designee, and RN Supervisor.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment and services. On review of RRNHV#4 the patient was prescribed wound treatments however there was no documentation noted in the record of the procedure that was preformed in the visit. The documentation noted skin care was provided per physicians orders, including gentle cleansing and application of prescribed topical products but the documentation did not specify what procedure was preformed and how it was tolerated as required. In RRNHV#5 there was also no documentation of the procedure performed as the documentation noted wound care as per POC. These observations were reviewed with the RN Supervisor, CEO. and LVN.

Observed in Competency Session. In 1 of 1 contracts reviewed, for inpatient contract reviewed, the organization failed to ensure a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice and a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This observation was reviewed with the CEO, and DPCS/Admin Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, HCO failed to provide patient education and training based on the patient's needs. In HV#3/RR#3, the surveyor observed that the oxygen concentrator being used by patient was not provided by the organization as per patient's request. No documentation was found in the patient's record addressing the risks associated with using equipment that is not being routinely maintained/serviced, nor a release of liability. This was addressed with the DPCS.

Observed in Record Review. In 6 of 6 patient records reviewed, HCO failed to assess patient's medical history through medical records, to determine if patient met eligibility criteria for hospice as evidenced by the clinical record did not contain any past medical history, lab results, other medical testing or even a physician referral for hospice evaluation. This was confirmed by the DPCS.