Every finding on record at Guardian Hospice

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 16 (Patient #1) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 1: Recent SN visit on 10/15/25 RN documents “Patient continues to complain of chest pain, mainly around the right rib area where the bone appears slightly protruded from an old fracture. He reports that pain in that area has become more intense recently. Pain assessment pain is described as Sharp and constant with intensity of “0”. On SN visit on 10/08/25, Pt reports persistent chest pain localized to right upper chest area, describing the pain as aching and sometimes sharp. States “Norco taken every 3 hours provides partial relief.” Also reports using marijuana to help control pain and improve relaxation.” On 10/22/25 during home visit, patient reports his goal for pain management is "0" holding up his hand to emphasize zero on 1-10 pain scale. Patient laughs stating "I guess I would have to be dead for my pain to ever be a zero." Upon interview with SN, it is reported patient is resistant to use of Morphine for pain management. There is no evidence of discussion of options for pain management and patient reports taking additional OTC acetaminophen 500 mg tablets and marijuana to attempt to self manage pain. COS agency discussed pain and use of OTC medications and marijuana with Medical Director and plans made for further education with patient by medical director and goals of patient discussion for pain management.

Upon patient record review, 1 of 16 (Patient # 13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 13: There is not evidence of patient right to request an attending physician was respected. Family requested Dr. Claiborne on readmission at SOC on 11/10/24.There is not evidence that patient’s chosen MD was contacted to request to follow as attending physician. Patient discharged on 9/15/25 due to request to be seen by family physician.

Upon patient record review 1 of 16 (Patient #2) 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 2: MSW visit 3/20/25 indicates visit made in person. MSW Narrative states “Patient not available to be assessed, will complete assessment once patient is available.” All areas remain blank on Psychosocial assessment as unassessed. There is no evidence of psychosocial assessment visit completion.

Upon patient record review, 3 of 16 (Patient 3, 7,16) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 3: The comprehensive assessment completed at SOC on 3/19/25 does not indicate imminence of death documentation. Patient 7: The comprehensive assessment completed at SOC on 4/11/24 does not indicate imminence of death documentation. Patient expired within 12 hours. Patient 16: The comprehensive assessment completed at SOC on 5/3/25 does not indicate imminence of death documentation.

Upon patient record review, 1 of 16 (Patient #1) 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: Upon home visit medication review, patient reports "I do not take Januvia and Metformin anymore. I only take Norco 10-325 mg every 3 hours and this Tylenol 500mg one tablet four times daily and I smoke marijuana to help with the pain and it helps me relax." Agency medication list does not contain OTC Acetaminophen 500 mg or not to exceed 4gms in 24 hours or the use of marijuana. Corrected on site with updates to medication list and obtained orders to limit 24 hour dose of acetaminophen and discontinue meds no longer taking.

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

Upon patient record review, 2 of 16 (Patient # 7, 8) 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 7: The POC on 4/11/24 contains an order for Eliquis with no evidence of risk for bleeding on the POC. Patient 8: The POC on 10/6/24 contains an order for Plavix with no evidence of risk for bleeding on the POC.

Upon patient record review, 1 of 16 (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 medications and treatments. Patient 1: Upon home visit medication review, patient reports "I do not take Januvia and Metformin anymore. I only take Norco 10-325 mg every 3 hours and this Tylenol 500mg one tablet four times daily and I smoke Marijuana to help with the pain and it helps me relax." Agency updated POC 10/16/25, contains orders for Januvia, Metformin, Norco 10-325mg every 3 hours prn, Acetaminophen 650mg rectal suppository every 6 hours prn. The updated POC does not contain orders for OTC Acetaminophen 500 mg or use of marijuana. Corrected on site with updates to POC and obtained orders to limit 24 hour dose of acetaminophen and discontinue meds no longer taking.

Upon patient record review, 3 of 16 (Patient # 9, 11,12) 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 9: The POC contains an order for Eliquis with no risk for bleeding identified on POC. Patient 11: Discharge documentation and POC does not include post-discharge care documentation. Summary reports "revocation to seek more aggressive treatment and Son wants to send father to rehabilitation facility." There is no evidence of planning to assist patient with placement in SNF and discharge planning. Patient 12: The updated POC on 9/4/24 contains orders for Clopidogrel and Aspirin daily with no evidence to assess or educate for risk of bleeding.

Upon patient record review, 2 of 16 (Patient # 1, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The updated POC 9/18/25 contains an order for LVN visits twice weekly. There is no evidence of LVN visits made. Agency reports LVN has been off work and is on medical leave. POC visit schedule has not been updated. COS with updates to POC. Patient 9: On 9/28/24, SN documents malfunction of G-tube reported by the aide. “Checked residuals through gravity. Checked G-tube patency by injecting 5 ml water and working well. Verified placement. There is no specified orders for the G-tube care performed by SN on updated POC 9/18/25.

Upon patient record review 1 of 16 (Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 2: SN visit on 3/20/25 SN documents "death not imminent. Patient has not eaten any food and only takes sips of water. I informed the family that my regular visit schedule is once every two weeks as an RN, except in emergencies, and that Annalyn (LVN) visits once a week.” There is not evidence nurse educated family on physical signs of dying process or increased visit schedule to meet needs of family during dying process. In addition, on 3/21/25 the RN documents “On March 21, 2025, a friend of daughter contacted the on-call service at 1:30am to report the patient’s passing. The on-call team then reached out to the daughter to confirm the death. The patient was officially pronounced deceased by the RN at 1:55am. There is no indication of a RN in person visit completed to pronounce patient at time of death or post mortem care of deceased person at death.

Upon observation and home visit, 1 of 1 (Patient 1) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: Upon observation at home visit, the SN does not observe agency bag technique policy for infection control when SN reaches into clean area of bag with gloved hands after providing direct patient care without removing gloves and performing hand hygiene prior to entering bag.

Upon patient record review 1 of 16 (Patient # 9) 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. Patient 9: There is no evidence of RN supervisory visits being completed for hospice aide after 8/25/24 through discharge 10/6/24.

Upon personnel record review, 4 of 13 (Personnel #2, 3, 4, and 6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #2: Competency assessment is signed off by self assessment. Personnel #3: Competency assessment is signed off by self assessment. Personnel #4: Competency assessment is signed off by self assessment. Personnel #6: Competency assessment is signed off by self assessment.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: There is not evidence of a physician designated by the hospice to assume the same responsibilities and obligations as the Medical Director when Medical Director is not available.

Condition of Participation: Clinical Records.

Upon patient record review, 6 of 16 (Patient # 1, 2, 5, 10, 11 and 14) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN 10/8/25 documents in SN visit note patient reports pain level as "0" and "Pt reports persistent chest pain localized to right upper chest area, describing the pain as aching and sometimes sharp". Pain assessment indicates incorrect use of pain intensity scale. Corrected on site with corrected documentation. Patient 2: The SN documents at death visit on 03/21/25 "Pronounced by facility staff" and patient expired at his home. Patient 5: The initial comprehensive assessment on 2/17/25, SC indicates telephone call completed instead of an in-person comprehensive visit and documents in narrative “chaplain visited the patient and introduced himself.” Patient 10: Initial comprehensive assessment is not signed or dated by RN on 6/22/24, Initial Comprehensive SC assessment on 6/23/24 not signed and dated by SCP. Patient 11: SN documents incorrect hospice name in discharge summary on 02/14/24 "Family requested to discharge and provided family with Pure Love Hospice Inc contact number." Patient 14: SN documents incorrect hospice name in discharge summary on 05/9/24 stating the patient/family is "Provided with contact number for Pure Hospice Inc.".

Upon patient record review, 1 of 16 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 11: Summary reports "revocation to seek more aggressive treatment and Son wants to send father to rehabilitation facility." There is no evidence the discharge summary was sent.

Upon patient record review, 4 of 16 (Patient #6,7,8,11) did not have evidence that the discharge summary includes all required information. Patient 6: Discharge summary does not include details including discharge orders, instruction, or status at time of discharge on 5/2/24. Patient 7: There is no evidence of a discharge summary. Patient 8: Discharge summary does not show evidence of details including discharge instructions, discharge orders, or status at time of discharge on 10/15/25. Patient 11: Discharge note states "Family requested discharge and provided family with Pure Love Hospice Inc contact number." Discharge summary does not include post-discharge care documentation. Summary reports "revocation to seek more aggressive treatment and Son wants to send father to rehabilitation facility."

Upon patient record review, 2 of 5 (Patient #1,#2) 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 and 2: The medical record contained nursing documentation stating patient continues taking Tylenol for pain There is no evidence of Tylenol on the medication profile. Corrected on site.

Upon patient record review, 2 of 5 (Patient #1,#2) 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 and 2: The medical record contained nursing documentation stating patient had pain and no evidence of goals and interventions related to pain. The medical record also contained documentation on the initial plan of care for Social Work visits and no evidence of problems, goals and interventions related to psychosocial problems identified.

Upon patient record review, 2 of 5 (Patient #1,#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 #1 and 2: The medical record contained nursing documentation stating patient had pain and continues taking Tylenol for pain. There is no evidence of an order for Tylenol. Corrected on site.

Upon patient client record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence that all entries complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1 and 2: On the initial nursing assessment the nurse documented the patient declined aide and volunteer services on the narrative and the initial plan of care however the initial nursing assessment states patient would like visits from the aide and volunteer services. (Discrepancies in documentation within the initial assessment). Patient #3: On the initial nursing assessment 6-20-22 the nurse documented the patient has an air mattress. The patient has no DME in the home. (Discrepancies in documentation). Patient #4: On the initial nursing assessment 2-19-22 the nurse documented the patient declined SC on the initial nursing assessment and initial plan of care states a frequency of contact within 5 days and then once a month for SC. (Discrepancies in documentation within the assessment). Patient #5: On the initial nursing assessment 4-17-22 the nurse documented no need for aide service. The documentation on the initial plan of care has an aide order for once per week. (Discrepancies in documentation).