Every finding on record at Cp Orange Co South S-Ca Hospice, LLC

Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care for one of three sampled patients (Patient 2).  This failure had the potential for not addressing the care needs for Patient 2.Findings: --- Review of the hospice’s P&P titled Hospice Initial and Comprehensive Assessment revised 3/7/26, showed a thorough assessment of the patient’s ongoing physical, emotional, psychosocial, and spiritual care and support needs as well as ongoing family/caregiver/representative needs and willingness to maintain care for the patient. This assessment is completed by the IDG in consultation with the patients’ attending if there is one, no later than five calendar days after the election of hospice services.Review of Patient 2’s clinical record was initiated on 4/29/26.  The clinical record showed the SOC was 1/21/26.  The patient was certified for hospice services during the certification periods from 1/21/26 to 3/21/26 and 3/22/26 to 5/20/26.The Hospice Election of Statement, Notice of Patient Rights, and Informed Consent dated 1/21/26, showed Patient 2 authorized for hospice services.The initial comprehensive nursing assessment was completed on 1/21/26.However, the initial comprehensive spiritual assessment for the patient was not completed.Review of the Client Coordination Note Report dated 1/22/26, showed the patient declined the services of the chaplain.  However, there was no documented evidence of the conversation between the chaplain and patient/family member regarding their spiritual care and needs.On 4/30/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome. The Director of Quality Outcome confirmed the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the imminence of death for one of three sampled patients (Patient 3).  This failure had the potential risk of not appropriately addressing the patient’s needs.Findings: --- Review of the hospice’s P&P titled Hospice Initial and Comprehensive Assessment revised 3/2/26, showed the comprehensive assessment includes consideration of other factors including imminence of death.Review of Patient 3’s clinical record was initiated on 4/30/26. The clinical record showed the SOC was 10/16/24. The patient was certified for hospice services during the certification periods from 10/16/24 to 12/14/24, 12/15/24 to 2/12/25, 2/13/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25, 10/11/25 to 12/9/25, 12/10/25 to 2/7/26, 2/8/26 to 4/8/26, and 4/9/26 to 6/7/26.Review of the initial comprehensive assessment dated 10/16/24, showed RN 2 had assessed the patient’s communication and body system (head-to-toe).The comprehensive assessment showed a guideline for identifying transitioning/imminent patients. However, RN 2 did not identify if Patient 3 was imminently dying.On 4/30/26 at 1345 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome. The Director of Quality Outcome confirmed the comprehensive assessment did not include the imminence of death.

Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 3).   This failure had the potential for the patient not receiving the appropriate care and necessary services that could negatively affect the patient well-being.Findings: --- The hospice’s P&P titled Medication Reconciliation and Management revised 10/28/25, showed in the facility setting, review the patient’s MAR at the medication cart to ensure a complete accounting of all current medications and treatments.Review of Patient 3’s clinical record was initiated on 4/30/26. The clinical record showed the SOC was 10/16/24. The patient was certified for hospice services during the certification periods from 10/16/24 to 12/14/24, 12/15/24 to 2/12/25, 2/13/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25, 10/11/25 to 12/9/25, 12/10/25 to 2/7/26, 2/8/26 to 4/8/26, and 4/9/26 to 6/7/26.On 4/29/26 at 0930 hours, a home visit was conducted with RN 1 and the Director of Quality Outcome to the assisted living facility where Patient 3 resided. The Client Medication Report showed the following medications:-morphine concentrate (opioid analgesic) 100 mg/5 ml (20 mg/ml) oral solution administered at 5 mg sublingually every three hours as needed showed the medication was used for mild pain. However, the morphine concentrate container at the facility showed the medication was used for moderate pain.-morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution administered at 10 mg sublingually every two hours as needed for severed pain.  However, the medication was not included in the assisted living facility's MAR.In addition, the patient’s assisted living facility MAR showed anti-diarrheal 2 mg one tablet by mouth four times daily as needed for diarrhea.  However, the anti-diarrheal medication was not included in the Client Medication Report.An interview and concurrent medication profile review was conducted with RN 1.  RN 1 confirmed the medication profile was not updated. The Director of Quality Outcome acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessment included the changes that occurred since the initial assessments, information on the patient's progress, and reassessment of the patient's responses for one of three sampled patients (Patient 2).  This failure had the potential of not addressing the care needs for Patient 2.Findings: --- Review of the hospice’s P&P titled Individualized Plan of Care revised 10/17/25, showed updates to the POC are based on information gathered during the comprehensive and on-going assessments of the patient and family/caregiver.  The updated POC is a collaborative document which provides a guide to the members of the IDG for the delivery of care and services which will achieve the patient’s goal.Review of Patient 2’s clinical record was initiated on 4/29/26.  The clinical record showed the SOC was 1/21/26.  The patient was certified for hospice services during the certification periods from 1/21/26 to 3/21/26 and 3/22/26 to 5/20/26.Review of RN 3’s subsequent visit dated 3/31/26, showed the following information:-Patient had complaint of new flank pain and sharp at times.  Morphine (opioid analgesic) 15 mg was not effective anymore.  The patient was refusing routine pain medications at this time.  The physician was notified and a new order to discontinue morphine and start Dilaudid (opioid analgesic) 2 mg by mouth every two hours as needed for pain.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/1/26, showed a new order to start Dilaudid 2 mg by mouth every two hours as needed for pain and to discontinue routine Norco (opioid analgesic).However, there was no documented evidence the IDG updated the comprehensive assessment as there was no dicussion of the patient’s complaint of new flank pain and that morphine was not effective anymore.On 4/30/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome verified the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for two of three sampled patients (Patients 1 and 3).  This failure had the potential for not providing appropriate, consistent, and quality care to the patients.Findings: --- Review of the hospice’s P&P titled Individualized Plan of Care revised 10/17/25, showed the POC is the complete treatment plan that provides the pathway for the hospice IDT to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the IDG team members, as well as input from the patient and/or caregiver as appropriate.  Content of the POC includes among others: all services needed to manage the terminal illness.1.  Review of Patient 1’s clinical record was initiated on 4/28/26. The clinical record showed the SOC was 2/27/26. The patient was certified for hospice services during the certification period from 2/27/26 to 5/27/26.Review of RN 4’s subsequent visit dated 4/2/26, showed wound care was provided on the patient's right elbow.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/26, showed the wound care was provided to the right elbow.However, there was no documented evidence the physician had ordered for a wound care to the right elbow.On 4/30/26 at 1300 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome confirmed the findings.2.  Review of Patient 3’s clinical record was initiated on 4/30/26. The clinical record showed the SOC was 10/16/24. The patient was certified for hospice services during the certification periods from 10/16/24 to 12/14/24, 12/15/24 to 2/12/25, 2/13/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25, 10/11/25 to 12/9/25, 12/10/25 to 2/7/26, 2/8/26 to 4/8/26, and 4/9/26 to 6/7/26.Review of the LPN subsequent visit dated 3/20/26, showed the patient’s buttocks were red and maintained with Calazinc (barrier cream).However, there was no documented evidence the physician had ordered Calazinc for Patient 3’s buttock redness.On 4/30/26 at 1345 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome. The Director of Quality Outcome verified the findings.

Based on interview and record review, the hospice failed to ensure individualized care plans were developed for one of three sampled patients (Patient 2).  This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement in the patient's health conditions.Findings: --- Review of the hospice’s P&P titled Individualized Plan of Care revised 10/17/25, showed the purpose is to provide instruction and direction for the development and documentation of the individualized plan of care for each patient including initial and updated plan of care documents to address both initial and comprehensive assessment of needs.Review of Patient 2’s clinical record was initiated on 4/29/26.  The clinical record showed the SOC was 1/21/26.  The patient was certified for hospice services during the certification periods 1/21/26 to 3/21/26 and 3/22/26 to 5/20/26.Review of RN 3’s subsequent visit dated 3/31/26, showed the patient had complaint of new flank pain and sharp at times.  Morphine (opioid analgesic) 15 mg was not effective anymore.  The patient was refusing the routine pain medications at this time.  The physician was notified and a new order to discontinue morphine and start Dilaudid (opioid analgesic) 2 mg by mouth every two hours as needed for pain.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/1/26, showed a new order to start Dilaudid 2 mg by mouth every two hours as needed for pain and to discontinue routine Norco (opioid analgesic).However, there was no documented evidence the IDG had developed an individualized POC to address Patient 2’s new flank pain and the adverse effects of the new pain medication ordered.  On 4/30/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome verified the finding.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: --- 1,  Review of Patient 1’s clinical record was initiated on 4/28/26. The clinical record showed the SOC was 2/27/26. The patient was certified for hospice services during the certification period from 2/27/26 to 5/27/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 3/26, 4/9, and 4/23/26, showed the patient’s identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, Patient 1 had a care plan addressing comfort.  Documentation showed one of the goals was for the patient/caregiver to understand symptom scales, management strategies, and when to report changes to hospice during visit and within 24 hours of new or worsening symptoms as evidenced by caregiver verbalizing understanding and appropriately contacting hospice when indicated. There was no documented evidence as to what symptom scales and management strategies were to be understood by the patient/caregiver.On 4/30/26 at 1300 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome confirmed the finding.2. Review of Patient 2’s clinical record was initiated on 4/29/26.  The clinical record showed the SOC was 1/21/26.  The patient was certified for hospice services during the certification periods from 1/21/26 to 3/21/26 and 3/22/26 to 5/20/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 2/4, 2/18, 3/4/26, 4/1, and 4/15/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, Patient 2 had a care plan addressing chronic and acute pain related to underlying medical condition/functional decline and immobility or disease progression.   Documentation showed the goal was for the patient to experience optimal pain control with pain level maintain at a tolerable level. However, there was documented evidence as to what was optimal pain and the pain level tolerable to the patient.On 4/30/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome verified the finding.3. Review of Patient 3’s clinical record was initiated on 4/30/26. The clinical record showed the SOC was 10/16/24. The patient was certified for hospice services during the certification periods from 10/16/24 to 12/14/24, 12/15/24 to 2/12/25, 2/13/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25, 10/11/25 to 12/9/25, 12/10/25 to 2/7/26, 2/8/26 to 4/8/26, and 4/9/26 to 6/7/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 2/4, 2/18, 3/4, 3/17, 4/1, and 4/15/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 3 had a care plan addressing comfort. Documentation showed one of the goals was for the pain medications to be administered according to the physician orders to achieve desired results and acceptable level as evidenced by pain less than "SIT" score.  There was no documented evidence as to what the acceptable pain level was for the patient.On 4/30/26 at 1345 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome verified the finding.

Based on interview and record review, the hospice failed to ensure the IDT had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for two of three sampled patients (Patients 1 and 2).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: --- The hospice’s P&P titled Individualized Plan of Care revised 10/17/25, showed the POC should be reviewed and revised as often as the needs of the patient indicate but not less than every 15 calendar days, unless other wise specified by state regulations.1.  Review of Patient 1’s clinical record was initiated on 4/28/26.  The clinical record showed the SOC was 2/27/26.  The patient was certified for hospice services during the certification period from 2/27/26 to 5/27/26.Review of RN 4’s Wound Assessment dated 3/23/26, showed the patient had a left forearm skin tear.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 3/26/26, showed the IDG had conducted a meeting.  The Client Orders showed a hospice physician order dated 3/23/26, for a wound care on the left forearm skin tear.  Documentation showed to cleanse with normal saline/wound cleanser, gently pat dry, apply Xeroform gauze (wound dressing), cover with a dry gauze; and change dressing every two to three days and PRN if soiled.However, the care plan was not updated as there was no documented evidence of a care plan for the wound care on the left forearm skintear.On 4/30/26 at 1300 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 4/29/26.  The clinical record showed the SOC was 1/21/26.  The patient was certified for hospice services during the certification periods from 1/21/26 to 3/21/26 and 3/22/26 to 5/20/26.Review of RN 3’s subsequent visit dated 3/31/26, showed the patient had complaint of new flank pain and sharp at times.  Morphine (opioid analgesic) 15 mg was not effective anymore.  The patient was refusing routine pain medications at this time.  The physician was notified and a new order to discontinue morphine and start Dilaudid (opioid analgesic) 2 mg by mouth every two hours as needed for pain.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/1 and 4/15/26, showed the IDG conducted the meetings.  Documentation showed the care plan was created on 1/21/26.  However, the care plan for chronic and acute pain was not updated. On 4/30/26 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator and Director of Quality Outcome. The Director of Quality Outcome confirmed the finding.3.  Review of RN 3’s subsequent visit dated 4/7/26, showed the patient reported falling twice in the last four to five days. Documentation showed the the first episode was outside on the patio with no injuries.  Documentation showded the second fall was inside the house.  Documentation showed the patient sustained some bruises on the face, lips, and forehead.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/15/26, showed the IDG had discussed the mentioned episodes of fall.Documentation showed the care plan was created on 1/21/26.  However, the care plan for high risk for falls was not updated.  On 4/30/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Administrator and Director of Quality Outcome.  The Director of Quality Outcome verified the findings.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#2 it was noted the patient developed a shin wound. The wound was not measured weekly or every nursing visit per organization Palliative Wound Care policy. The wound documentation lacked measurements for 3 out of 5 weekly visits reviewed. This was discussed with the Quality Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#5 it was noted on a communication note by an LVN the beginning of January 2024 that the patient had a fever with cough and congestion. This clinical finding was not discussed at the IDG meeting the middle of January 2024.

Observed in Record Review. In 6 of 14 patient records reviewed, During RR#2 it was noted the patient terminal diagnosis was protein calorie malnutrition. The POC lacked goals related to the nutritional deficit. In addition the patient developed a UTI and URI with medication orders for antibiotics. Goals were not added to the POC to address the deficits identified. During RR#4 it was noted the POC lacked goals related to the respiratory deficit/primary diagnosis, COPD. During RR#5 it was noted a communication note that stated the facility where the patient resided had a scabies infestation, the MD was called with an order for scabies prophylaxis treatment. Goals were not added to the POC related to the problem identified and the treatment. In addition, in January 2024, the patient developed a fever, cough, and lung congestion with an antibiotic order added to the medication profile. The POC lacked goals related to the respiratory status. During RR#6 it was noted lack of goals related to a neurological deficit of brain metastasis secondary to melanoma with medication orders for keppra and dexamethasone on the POC. During RR#7 it was noted in January 2024 SN notes, the patient was having difficulty with swallowing due to a neck tumor. Goals were not added to the POC to address the clinical issue. During RR#9 it was noted lack of goals on the POC to address the stage 3 pressure ulcer on the patient's coccyx. This was discussed with the Clinical Leadership.

Observed in Record Review. In 6 of 14 patient records reviewed, During RR#2 it was noted the patient terminal diagnosis was protein calorie malnutrition. The POC lacked interventions related to the nutritional deficit. In addition the patient developed a UTI and URI with medication orders for antibiotics. Interventions were not added to the POC to address the deficits identified. During RR#4 it was noted the terminal diagnosis was COPD. The POC lacked interventions related to the respiratory deficit/primary diagnosis. During RR#5 it was noted a communication note that stated the facility where the patient resided had a scabies infestation, the MD was called and received an order for scabies prophylaxis treatment. Interventions were not added to the POC to assess the patient's skin and instruct on s/s scabies and affect of prophylaxis treatment. In addition, in January 2024, the patient developed a fever, cough and lung congestion with an antibiotic order added to the medication profile. The POC lacked interventions to assess the respiratory status and instruct on S/S respiratory infection and use of antibiotic medication. During RR#6 it was noted a primary diagnosis of melanoma and brain metastasis. Medications orders on the POC included keppra and dexamethasone. The POC lacked interventions related to the documented neuro deficits. During RR#7 it was noted in January 2024 SN notes the patient was having difficulty with swallowing due to a neck tumor. Interventions were not added to the POC to address the clinical issue. During RR#9 it was noted lacked of interventions added to the POC to address the stage 3 pressure ulcer on the patient's coccyx. This was discussed with the Clinical Leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#9 it was noted on the RN note an order for wound care for a stage 3 pressure ulcer on the patient's coccyx. The order lacked the frequency of the wound care to be performed and direction on who would perform the wound care. Observed in Record Review. In 2 of 14 patient records reviewed, During RR#3 it was noted the patient medication profile contained an order for Haldol 1mg PO q 6 hours as needed for agitation and Haldol 2mg q6hours as needed for agitation. The orders did not indicate when to give each dose. During RR#5 it was noted an order for Tramadol 50 mg every 6 hours PRN pain and Acetaminophen 500 mg 2 tabs every 6 hours for pain. The orders did not indicate when to give each medication. This was discussed with the Quality Manager. Observed in Record Review. In 2 of 14 patient records reviewed, During RR#2 it was noted an order for oxygen therapy 2-5L PRN shortness of breath. The order lacked the parameters to increase the oxygen flow. During RR#5 it was noted an order for Oxygen therapy at 2L PRN dyspnea, 2L mild dyspnea, 3L moderate dyspnea, 4L severe dyspnea. The order lacked the clinical assessment parameters of minimal, moderate and severe dyspnea due to the patient's inability to self report dyspnea. This was discussed with the Quality Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#5 it was noted in SN notes that the patient was using a wheelchair. The wheelchair was not added to the DME list on the POC. This was discussed with the Clinical leaders.

Observed in Patient Home. In 1 of 4 home visits conducted, During HV#1 it was noted the SN did not adhere to the organization Policy # 14913282, Infection Prevention, Standard Precautions. It was noted the SN after washing his hands donned a pair of gloves, then gathered the supplies needed to provide wound care from the facility medication cabinet and then entered his bag without disinfecting his hands. The SN entered his nursing bag multiple times without removing his gloves and disinfecting his hands. This was observed and discussed with the Clinical Manager who was present during the visit.

Observed in Regulatory Review. It was noted during the volunteer program review, volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. The percentage recorded and presented to the surveyor was 1.01% in 2023. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#9 its was noted by the SN the presence of a stage 3 pressure ulcer on coccyx. The documentation lacked any further description of the pressure ulcer such as measurements and other descriptors of the pressure ulcer. This was discussed with the Clinical Leadership.