Every finding on record at Liberum Hospice Care, Inc

Upon patient record review, 3 of 5 (Patient #1,2,3) 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: The POC 10/17/24 contains an order for MSW and SC initial assessment, at recert and as needed with no frequency for the as needed visits. Corrected on site. Patient 2: The POC 10/12/24 contains an order for MSW and SC initial assessment, at recert and as needed with no frequency for the as needed visits. Corrected on site. Patient 3: The POC 10/04/24 contains an order for MSW and SC initial assessment, at recert and as needed with no frequency for the as needed visits. Corrected on site.

Upon patient record review, 2 of 5 (Patient #3,5) 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: The SN documented on comprehensive assessment 10/4/24 "SN provided teaching to PCG on skin management. Do not let patient sit on diaper for prolonged periods of time. Use appropriate barrier cream". There is no evidence of an order for barrier cream. Patient 5: The SN documented on 9/30/24 "pt started taking Lactulose daily as needed for constipation". There is no evidence of an order for lactulose. Corrected on site.

Upon patient record review, 1 of 5 (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 equipment and supply needs. Patient 3: The POC has pt on Ipratropium/Albuterol treatments. There is no order for a nebulizer on the POC. Corrected on site.

Upon patient record review, 2 of 5 (Patient #2,3) 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 2: The aide POC 10/14/24 contains change linens with no frequency. Corrected on site. Patient 3: The aide POC 10/6/24 contains change linens with no frequency. Corrected on site.

Upon patient client record review, 1 of 5 (Patient #4) 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 4: The SN documented 10/20/24 "SN gave PRN morphine" there was no documentation to detail that the SN administered morphine according to the POC.

Upon patient record review 2 of 14 (Patient #5,8) 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 5,8: There is no evidence of initial psychosocial assessment.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,7,8) 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: Medication list for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Medication list for A and D ointment. Apply thin layer ointment topical twice daily and PRN for dry skin. There is no evidence of application site. Medication list Aveeno moisturizing lotion. May use equivalent moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 2: Medication list for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Medication list for A and D ointment. Apply thin layer ointment topical twice daily and PRN for dry skin. There is no evidence of application site. Medication list for Aveeno moisturizing lotion. May use equivalent moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. Medication list for Ensure oral between meals for poor appetite daily and PRN for nutritional supplement. There is no evidence of amount per dose. COS Patient 3: Medication list for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Medication list for Aveeno moisturizing lotion. May use equivalent moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 5: Medication list for cal-protect ointment. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 07/31/2023 for moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 7: Medication list for menthol and zinc topical ointment 0.44 percent-20.625 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Medication list for moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 8: Medication list for calmoseptine ointment, or any equivalent moisture barrier cream. Apply thin layer ointment topical every shift for skin management. There is no evidence of application site. Medication list for moisturizing lotion. 1 to skin daily for skin management. There is no evidence of application site. There is no evidence of dose. Medication list for Nystatin 100,000 units per gram topical powder. Apply thin layer topical twice daily for irritant dermatitis. There is no evidence of application site. COS

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

Upon patient record review, 5 of 14 (Patient #3,5,6,7,10) 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 3: There is evidence of wounds in the medical record. DTI to left heel: There is no evidence of wound measurements or assessment after 06/20/2024. On 06/20/2024, the wound was assessed, but not measured. Skin tear to left forearm: no evidence of wound assessment or measurements. Per the policy of this hospice, measurement and assessment should occur no less than every two weeks. Patient 5: Patient’s g-tube site is listed as a wound site without further information. This occurred on dates: 06/24/2024, 07/08/2024, 07/22/2024. No evidence of measurements or assessment of wound site noted in the clinical record. Patient 6: There is evidence of wounds in patient’s medical record. Wound 1: Pressure injury to coccyx/sacrum. There is no evidence of measurements or assessment in the medical record 06/06/2024-08/29/2024. Wound 2: Left first metatarsal. Open 11/15/2023 and resolved 06/12/2024. There is no evidence of measurements or assessments in the medical record. Patient 7: There is documentation that patient fell on 07/07/2024. Per the post-fall policy/procedure of this hospice, the SN is to visit the patient post-fall. This is expected to be the same day; within 4 hours if possible. There is no evidence this patient was seen by SN until 07/13/2024. Patient 10: On 08/05/2024, there is documentation in the clinical record that patient suffered a skin tear related to a fall. On this same date, the skin tear was assessed and measured. There is no evidence that the skin tear has been measured or assessed since that date. Per the policy of this hospice, measurement and assessment should occur no less than every two weeks.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,7) 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. Please note: all below COS Patient 1: Patient has aspiration precautions on the plan of care. There is no evidence of aspiration precautions in the patient’s nutrition care plan. Patient’s documented Braden score is 13. There is no evidence of a care plan for skin breakdown risk. Generalized pruritis goal timeline 10-14 days. This care plan is still active, despite being opened 09/11/2023. Patient 2: Pain care plan has active issue = generalized pain related to history of right hip surgery. Right hip surgery occurred before hospice admission on 06/01/2023. Patient has Braden score of 12 and no evidence of care plan for skin breakdown risk. Patient has order for oxygen in the medical record. There is no evidence of a respiratory care plan and/or an oxygen care plan. Patient 3: Patient with physician’s order for oxygen. There is no evidence of respiratory and/or oxygen care plan in the medical record. Patient’s Braden score is 13. Further, patient has documented wounds. There is no evidence of a care plan for skin breakdown risk in the medical record. There is also no evidence of a wound care plan in the medical record. Patient has documented pitting edema. There is no evidence of a cardiac/edema care plan in the medical record. Patient 5: Patient has evidence of aspiration precautions on the plan of care. There is no evidence of a nutrition care plan with aspiration precautions as an intervention in the medical record. Patient has oxygen physician’s order. There is no evidence of a respiratory/oxygen care plan in the medical record. Patient has an identified wound. There is no evidence of a wound care plan in the medical record. Patient has an open care plan for s/p COVID pneumonia. This care plan was open 07/31/2023. Patient 6: Patient has documented stage 4 wound to coccyx/sacrum. This wound was originally documented as a stage 3 wound. There is no evidence that the patient’s care plan has been updated to reflect the worsening of the wound. Patient had wound to left first metatarsal. This wound resolved 6/12/24. There is no evidence that the patient’s care plan has been updated to reflect this change. Patient 7: Patient has documented seizure precautions on the plan of care. There is no evidence of a seizure precautions care plan in the medical record.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,7,8) 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: Physician’s order written 06/26/2023 for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 06/26/2023 for A and D ointment. Apply thin layer ointment topical twice daily and PRN for dry skin. There is no evidence of application site. Physician’s order written 06/26/2023 Aveeno moisturizing lotion. May use equivalent moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS. Respiratory care plan includes intervention of oxygen ordered via nasal cannula at 2LPM. The physician’s order for oxygen includes a flow rate of 2-4LPM PRN., conflicting orders. Patient 2: Physician’s order written 06/01/2023 for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 06/01/2023 for A and D ointment. Apply thin layer ointment topical twice daily and PRN for dry skin. There is no evidence of application site. Physician’s order written 06/01/2023 for Aveeno moisturizing lotion. May use equivalent moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. Physician’s order written 06/01/2023 for Ensure oral between meals for poor appetite daily and PRN for nutritional supplement. There is no evidence of amount per dose. COS Patient 3: Physician’s order written 06/17/2023 for calmoseptine 0.44 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 06/17/2023 for Aveeno moisturizing lotion. May use equivalent Patient 5: Physician’s order written 07/31/2023 for cal-protect ointment. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 07/31/2023 for moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 7: Physician’s order written 01/14/2024 for menthol and zinc topical ointment 0.44 percent-20.625 percent. Apply thin layer ointment topical twice daily and PRN for incontinence management. There is no evidence of application site. Physician’s order written 01/14/2024 for moisturizing lotion. Apply thin layer topical twice daily and PRN for dry skin. There is no evidence of application site. COS Patient 8: Physician’s order written 06/07/2024 for Calmoseptine ointment, or any equivalent moisture barrier cream. Apply thin layer ointment topical every shift for skin management. There is no evidence of application site. Physician’s order written 06/07/2024 for moisturizing lotion. 1 to skin daily for skin management. There is no evidence of application site. There is no evidence of dose. Physician’s order written 06/07/2024 for Nystatin 100,000 units per gram topical powder. Apply thin layer topical twice daily for irritant dermatitis. There is no evidence of application site. COS

Upon patient record review, 3 of 14 (Patient #1,2,5) 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: ADL care plan includes intervention for utilization of trapeze and hoyer lift. These DME are not part of this patient’s POC. Patient 2: Patient’s ADL care plan includes intervention for utilization of side rails, trapeze and hoyer lift. There is no evidence of these DME on the patient’s POC. Patient 5: ADL care plan includes intervention for utilization of side rails, trapeze and hoyer lift. There is no evidence of these DME on the patient’s plan of care.

Upon client record review, 6 of 14 (Patient #1,2,3,6,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Patient was seen on 07/28/2024 and 08/06/2024 by LVN. On both occasions, LVN documented, “emphasized perineal care, recommended routine use of zinc oxide cream to prevent skin breakdown and bedsores.” There is no evidence of a physician’s order for zinc oxide in the plan of care. On these same dates, LVN documented: treatment provided on underneath skin folds redness with nystatin powder with good improvement. There is no evidence of physician’s order for Nystatin on the plan of care. Patient 1,2: Physician’s order for SN visit frequency written 06/01/2023 (a Thursday) with a start date of 06/01/2023. The first SN visit was made on 06/04/2024 (a Sunday). There is no evidence of a SN visit 06/01/2023-06/03/2023. Patient 3: Physician’s order for SN visit frequency written 06/17/2023 (a Saturday) with a start date of 06/17/2023. The first SN visit was made on 06/20/2024 (a Tuesday). There is no evidence of a RN visit 06/17/2023. Physician’s order for RN visit frequency written 06/17/2023 (a Saturday) with a start date of 06/17/2023. There is no evidence of a RN visit 06/17/2023. Patient 6: Physician’s order for RN frequency written 11/15/2023 is weekly. There is evidence of RN visits on the following dates, noted to be less frequent than weekly: 07/18/2024, 08/01/2024, 08/15/2024, 08/29/2024. RN visit frequency has been updated to once every 2 weeks. Patient 8: Physician’s order for SN visit frequency written 06/07/2024 (a Friday) with a start date of 06/07/2024. The first SN visit was made 06/11/2024 (a Tuesday). There is no evidence of a SN visit 06/07/2024-06/08/2024. Physician’s order for RN frequency written 06/07/2024 (a Friday) with a start date of 06/07/2024. The ordered frequency is weekly. The first RN visit was made 06/20/2024. Additionally, there is evidence that RN visits have been made: 06/20/2024, 07/04/2024, 07/18/2024, 08/01/2024, 08/15/2024. These visits are noted to be less frequent than weekly. RN visit frequency has been updated to once every 2 weeks. Patient 9: Physician’s order for SN visit frequency written 06/13/2024 (a Thursday) with a start date of 06/13/2024. The first SN visit was made 06/20/2024 (a Thursday). There is no evidence of a SN visit 06/13/2024-06/15/2024.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 8 of 14 (Patient #1,2,3,5,6,7,8,10) 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: There is evidence that the aide care plan has tasks assigned without frequency. These tasks are: turn and reposition; dressing in street clothes; change patient linens. Additionally, the patient has oxygen ordered. Oxygen is not in aide care plan. Patient 2,3: There is evidence that the aide care plan has tasks assigned without frequency. These tasks are: dressing in street clothes; change patient linens. Additionally, the patient has oxygen ordered. Oxygen is not in aide care plan. Patient 5: There is evidence that the aide care plan has tasks assigned without frequency. These tasks are: transfer; dressing in pajamas/gown; change patient linens. Additionally, the patient has oxygen ordered. Oxygen is not in aide care plan. Patient 6,7: There is evidence that the aide care plan has tasks assigned without frequency. These tasks are: transfer patient. Additionally, the patient has oxygen ordered. Oxygen is not in aide care plan. Patient 8,10: There is evidence that the aide care plan has tasks assigned without frequency. These tasks are: transfer patient.

Upon patient record review 5 of 14 (Patient #1,2,3,6,8) 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 1,2: Physician’s order for aide visit frequency written 06/01/2023 (a Thursday) with a start date of 06/01/2023. The first aide visit was made on 06/05/2024 (a Monday). There is no evidence of an aide visit 06/01/2023-06/03/2023. Patient 3: Patient 3: Physician’s order for aide visit frequency written 06/17/2023 (a Saturday) with a start date of 06/17/2023. The first aide visit was made on 06/19/2024 (a Monday). There is no evidence of an aide visit 06/17/2023. Patient 6: Physician’s order for aide frequency written 11/15/2023 is twice weekly. There is no evidence of aide visits made between 07/18/2024 and 07/26/2024. Patient 8: Physician’s order for aide visit frequency written 06/07/2024 (a Friday) with a start date of 06/07/2024. The first aide visit was made 06/10/2024 (a Monday). There is no evidence of an aide visit 06/07/2024-06/08/2024.

Upon client record review, 1 of 14 (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: There is no evidence of documentation in patient's medical record re: discharge summary forwarded to primary physician after discharge

Upon SNF/NF contract review, 2 of 2 (Monterey Park Convalescent and Atherton Baptist) 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. Neither contract stated how documentation of communication is to occur.