Every finding on record at Eagles Wings Hospice LLC

Upon patient record review, 7 of 14 (Patient #1,3,4,5,8,9,10) 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 1,3,4,5,9,10: Oxygen is listed on the plan of care as a treatment. There is no evidence of this medication on the medication list. COS Patient 1: Medication list with medication Ketotifen Fumarate 0.035% ophthalmic solution. Instructions read one drop twice daily to affected eye as needed for allergies. There is no evidence of application site for this medication on the medication list. COS Patient 3: Medication list with the following medications: topical Calmoseptine 0.44%. Instructions read apply topical 4 times daily as needed for rash. Lidocaine 4% transdermal patch. The instructions read apply one patch 12 hours on/12 hours off for pain. Triamcinolone acetone 0.1% lotion. Instructions read apply 3 times a day as needed for skin irritation. There is no evidence of application site for these medications on the medication list. All COS Patient 5: Medication list with the following medications: Ivizia dry solution 0.5%. Instructions are one drop ophthalmic twice daily for glaucoma. Systane complete 0.6% lubricant eye drops. One drop ophthalmic twice daily for dry eyes. There is no evidence of administration site for these medications on the medication list. COS Patient 8: Medication list with the following medication: Ocular lubricant ophthalmic solution. Instructions are one drop every four hours for dry eyes. There is no evidence of administration site for this medication on the medication list. COS Patient 10: Medication list with the following medications: Azelastine hydrochloride 0.15%/187 mcg nasal spray. Instructions: 2 sprays daily as needed. Lidocaine 5% transdermal patch. Instructions: Apply every other day, 12 hours on/12 hours off, alternating with Voltaren gel. There is no evidence of Voltaren gel in the medication list. Nystatin 100,000 units/gram powder. Instructions: 1 gram topical twice daily for redness. There is no evidence of administration site for these medications on the medication list. COS SSD 1% topical cream. Instructions: 1 gram topical daily to wounds/rash. Treatment order for wound: coccyx stage II: cleanse with soap and water. Pat dry. Apply A&D ointment every diaper change. Apply TAO 3 times per week and PRN. There is no evidence of SSD being used in this treatment. There is also no evidence of any other treatments in the medical record. COS Nitroglycerin 0.4mg sublingual tablet. Instructions: one tablet every 5 minutes sublingual for chest pain. Call hospice if no relief. There is no evidence of minimum/maximum doses or other instructions for this medication on the medication list. COS

Upon patient record review, 4 of 14 (Patient #1,3,4,5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: There is no evidence of RN visit documented between dates 4/18/25 and 5/10/25; 22 days. Patient 3: The most recent RN visit documented in the medical record is dated 4/22/25. This is 20 days at the start of survey. Patient 4: The most recent RN visit documented in the medical record is dated 4/5/25. This is 37 days at the start of survey. Patient 5: The most recent RN visit documented in the medical record is dated 4/4/25. This is 38 days at the start of survey. Late entry visits dated 4/18/25 and recertification visit dated 5/2/25 entered during survey. These both include supervisory visits.

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, 2 of 14 (Patient #3,7) 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 3: Edema identified as a problem during initial assessment, dated 3/25/25. Additionally, patient was prescribed furosemide 40mg by mouth daily for edema. There is no evidence of plan of care for edema, including problems, goals, and interventions. COS Patient 7: Patient has order for aspirin 81mg by mouth daily for anticoagulation, prescribed at admission on 3/6/25. There is no evidence of plan of care for high risk of bleeding, including problems, goals, and interventions. COS

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,9,10,13) 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. Patient 1,2,3,4,5,6,9: Physician’s social work visit frequency order is once per certification period and as needed per family request. There is no evidence of a quantifier for the PRN visits. Physician’s SC visit frequency order is once per certification period and as needed per family request. There is no evidence of a quantifier for the PRN visits. COS Patient 10,13: Physician’s social work visit frequency order is once per certification period and as needed per family request. There is no evidence of a quantifier for the PRN visits. Patient 10 COS

Upon patient record review, 7 of 14 (Patient #1,3,4,5,8,9,10) 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 1,3,4,5,9,10: Oxygen is listed on the plan of care as a treatment. There is no evidence of this medication order on the plan of care. COS Patient 1: Plan of care with medication Ketotifen Fumarate 0.035% ophthalmic solution. Instructions read one drop twice daily to affected eye as needed for allergies. There is no evidence of application site for this medication on the plan of care. COS Patient 3: Plan of care with the following medications: topical Calmoseptine 0.44%. Instructions read apply topical 4 times daily as needed for rash. Lidocaine 4% transdermal patch. The instructions read apply one patch 12 hours on/12 hours off for pain. Triamcinolone acetone 0.1% lotion. Instructions read apply 3 times a day as needed for skin irritation. There is no evidence of application site for these medications on the plan of care. All COS Patient 5: Plan of care with the following medications: Ivizia dry solution 0.5%. Instructions are one drop ophthalmic twice daily for glaucoma. Systane complete 0.6% lubricant eye drops. One drop ophthalmic twice daily for dry eyes. There is no evidence of administration site for these medications on the plan of care. COS Patient 8: Plan of care with the following medication: Ocular lubricant ophthalmic solution. Instructions are one drop every four hours for dry eyes. There is no evidence of administration site for this medication on the plan of care. COS Patient has oxygen plan of care including problems, goals, interventions in the medical record. There is no evidence of physician’s order for oxygen in the medical record. COS Patient 10: Plan of care with the following medications: Azelastine hydrochloride 0.15%/187 mcg nasal spray. Instructions: 2 sprays daily as needed. Lidocaine 5% transdermal patch. Instructions: Apply every other day, 12 hours on/12 hours off, alternating with Voltaren gel. There is no evidence of Voltaren gel in the plan of care. Nystatin 100,000 units/gram powder. Instructions: 1 gram topical twice daily for redness. There is no evidence of administration site for these medications on the plan of care. COS SSD 1% topical cream. Instructions: 1 gram topical daily to wounds/rash. Treatment order for wound: coccyx stage II: cleanse with soap and water. Pat dry. Apply A&D ointment every diaper change. Apply TAO 3 times per week and PRN. There is no evidence of SSD being used in this treatment. There is also no evidence of any other treatments in the medical record. COS Nitroglycerin 0.4mg sublingual tablet. Instructions: one tablet every 5 minutes sublingual for chest pain. Call hospice if no relief. There is no evidence of minimum/maximum doses or other instructions for this medication on the plan of care. COS

Upon patient record review, 3 of 14 (Patient #1,5,10) 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: Identified DME need with no evidence of DME on the plan of care: shower chair, hospital bed. Patient 5: Identified DME need with no evidence of DME on the plan of care: hospital bed, overbed table. COS Patient 10: Identified DME need with no evidence of DME on the plan of care: standard wheelchair COS

Upon client record review, 6 of 14 (Patient #1,2,4,7,8,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 1,2,4,7,8,10: There is no evidence of a spiritual care participation 5/1/25 IDG as there is not note to show review and revision and collaboration. SC making routine visits to these patients.

Upon patient record review, 2 of 14 (Patient #5,10) 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 5: Oxygen was prescribed for patient after initial comprehensive assessment, dated 11/15/2024. There is no evidence of oxygen plan of care including problems, goals, and interventions in the medical record. COS Patient 10: Treatment and medication orders for wound care added to the plan of care on 3/8/25. There is no evidence of wound plan of care including problems, goals, interventions in the medical record. COS

Upon client record review, 8 of 14 (Patient #1,2,3,4,5,7,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s SN visit frequency order, dated 12/6/24, is weekly and 3PRN. There is no evidence of a nursing visit made 4/24/25-5/10/25; 12 days. Patient 2: Physician’s SN visit frequency order, dated 4/14/25, is twice weekly and 3PRN. There is no evidence of SN visit made after 4/29/25. Late entry RN visits documented during survey. These are dated 4/28/25 and 5/12/25. Both visits include supervisory visits. Patient 3: Physician’s SN visit frequency order, dated 3/25/25, is weekly and 3PRN. There is no evidence of SN visit made after 4/30/25; 12 days at start of survey. Patient 4: Physician’s SN visit frequency orders: 12/14/24 to 12/30/24: weekly. 12/30/24 to 1/27/25: twice weekly. 1/27/25 to present: weekly. There is no evidence of scheduled SN visit made 1/17/25 to 1/25/25. Patient 5: The most recent RN visit documented in the medical record is dated 4/4/25. This is 38 days at the start of survey. Late entry visits dated 4/18/25 and recertification visit dated 5/2/25 entered during survey. These both include supervisory visits. Patient 7: Physician’s SN visit frequency order, dated 3/6/25, is twice weekly and 3PRN. With the exception of the week of 3/9/25; there is only one SN visit documented each week. During this week, there were 2 visits documented; 3/10 and 3/14/25. Clarification order written 5/13/25: SN visit frequency weekly since admission. Patient 9: Physician’s SN visit frequency order, dated 2/13/25, is twice weekly and 3PRN. There is no second SN visit documented during week of 2/13/25. There are 3 SN visits documented during week of 2/16/25: 2/17, 2/20, 2/22/25. There is one documented SN visit during weeks: 4/27/25, on 4/29/25 and 5/4/25, on 5/8/25. Late entry SN visits were entered into the record during survey. These visits are dated 5/2/25 and 5/9/25. Patient 10: Physician’s SN visit frequency order, dated 1/15/25, is twice weekly and 3PRN. There is only one SN visit documented during week of 5/4/25, dated 5/7/25.

Condition of participation: Hospice aide and homemaker services. All hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section.

Upon patient record review, 4 of 14 (Patient #1,2,3,5) 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: Tasks on the aide plan of care without noted frequencies: record bowel movement; transfer per 1 person assist; feeding assistance; change patient’s linen. COS Patient 2,5: Task check patient’s vital signs every visit is noted on patient’s aide plan of care. There is no evidence of parameters for vital signs check in the plan of care. COS Patient 3: Tasks on the aide plan of care without noted frequencies: 2 bedrails up; turn and reposition; 1 person transfer; change patient’s linen. COS Patient 5: Tasks on the aide plan of care without noted frequencies: record bowel movement; transfer per 1 person assist; change patient’s linen. COS

Upon patient record review 6 of 14 (Patient #1,2,4,5,7,10) 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 1,5: Physician’s aide visit frequency order is twice weekly. The most recent documented aide visit is 4/29/25. Patient 2: Physician’s aide visit frequency order is twice weekly, written 4/14/25. There is documentation of one aide visit during week one, 4/18/25. Patient 4: Physician’s aide visit frequency order is twice weekly. The most recent documented aide visit is 4/28/25. Patient 7: Physician’s aide visit frequency order is twice weekly, written 3/6/25. There is no evidence of aide visits made to this patient in the medical record. Clarification order written 5/13/25: Aide offered and declined during admission. Patient 10: Patient Physician’s aide visit frequency order is twice weekly, written 1/15/25 and discontinued 1/27/25. On 1/27/25, order was changed to three times a week. Week one, there is one documented aide visit, dated 1/17/25. During the week of 1/19/25, there are 3 aide visits documented, dated 1/20, 1/22, and 1/24/25. Clarification order written 5/13/25: Aide visits changed to 3 times weekly, effective 1/19/25, not 1/27/25.

Upon patient record review 3 of 14 (Patient #1,2,4) 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. 629 1,2,4 Patient 1: Patient’s aide visit frequency order is twice weekly. The most recently documented aide supervisory visit is dated 4/18/25; 24 days at the beginning of survey. Patient 2: Physician’s aide visit frequency order is twice weekly, written 4/14/25. There is no evidence of RN supervisory visit documented in the medical record. Patient 4: Physician’s aide visit frequency order is twice weekly, written 1/13/25. The most recent supervisory visit documented in the medical record is dated 4/5/24.

Upon contract review, 2 of 3 (Murrieta Health and Rehab and Ramona Rehab and Post Acute Care) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care SNF contracts 1: Murrieta Health and Rehab and 2: Ramona Rehab and Post Acute Care Section 6.4 of both contracts state, "Because hospice and facility will work together to care for the same patients and will share integrated systems of quality assessment for these entities will function together as an organized healthcare arrangement ("OCHOA") FOR THE PURPOSES OF COMPLYING WITH THE Health Insurance Portability and Accountability Act of 1996 Standards for Privacy of Individually Identifiable Health Information ("HIPAA Privacy Standards"). See Appendix "C". There is no evidence of Appendix C attached to these contracts. Revised contract was sent to both SNFs for signature on survey day 3, and at survey’s end, hospice was awaiting SNF administrators signatures. Revised contracts included delineation of responsibilities.

Upon patient client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,10,13) 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 1,2,3,4,5,6,7,8,10,13: On the hospice notice of election, patient/caregiver (for the patient) indicated they wanted to receive a copy of the non-covered items, services, and drugs. There is no evidence the patient received a copy of this form.

Upon SNF/NF contract review, 2 of 3 (Murrieta Health and Rehab and Ramona Rehab and Post Acute Care) did not have evidence the contract specifies the provision of hospice services in the facility and that the contract is signed by authorized representatives of the hospice and the SNF/NF or ICF/IID before the provision of hospice services. SNF contracts 1: Murrieta Health and Rehab and 2: Ramona Rehab and Post Acute Care Contract article XIX: miscellaneous general provisions Section 19.1: The agreement is bound by the terms and conditions set forth in appendix "D." There is no evidence of Appendix D attached to these contracts.

Upon SNF/NF contract review, 2 of 3 (Murrieta Health and Rehab and Ramona Rehab and Post Acute Care) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day. SNF contracts 1: Murrieta Health and Rehab and 2: Ramona Rehab and Post Acute Care In both contracts, there is no evidence of communication requirement. Revised contract was sent to both SNFs for signature on survey day 3, and at survey’s end, hospice was awaiting SNF administrators signatures. Revised contracts stated that there will be regular communication between hospice and SNFs and all communication will be documented.

Upon SNF/NF contract review, 2 of 3 (Murrieta Health and Rehab and Ramona Rehab and Post Acute Care) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel. SNF contracts 1: Murrieta Health and Rehab and 2: Ramona Rehab and Post Acute Care In both contracts, there is no evidence that hospice will be required to provide bereavement services to facility staff. Revised contract was sent to both SNFs for signature on survey day 3, and at survey’s end, hospice was awaiting SNF administrators signatures. The revised contracts contain language that state that in addition to family bereavement services, hospice will provide bereavement to facility staff for up to 13 months after the death of a hospice patient.