Every finding on record at Luna Vista Hospice LLC

Upon patient record review 2 of 14 (Patient #2,9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2 - The medical record showed a start of care date for 08/15/25. The medical record showed the spiritual care comprehensive assessment was completed on 08/21/25 and the MSW comprehensive assessment was completed on 08/22/25. There was no documented evidence of reason for delay. Patient #9 - The medical record showed a start of care date for 10/09/25. The spiritual care comprehensive assessment was completed on 10/17/25, with documentation of late visit reason due to spiritual coordinator's schedule.

Upon patient record review, 1 of 14 (Patient #4) 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 #4 - The medication profile listed Tylenol 500mg - take 1-2 tablets every 6 hrs as needed. There was no evidence of a maximum acetaminophen daily dose listed.

Upon patient record review, 2 of 14 (Patient #2,12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2 - The medical record showed a start of care date for 08/15/25. There is no evidence that an initial bereavement risk assessment was completed until 08/21/25. Patient #12 - The medical record showed a start of care date for 03/16/25. There was no evidence that an initial bereavement risk assessment was completed until after the patient expired on 04/06/25.

Upon patient record review, 4 of 14 (Patient #1,4,6,10) 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 - Patient's advanced directives showed patient chose to be a full code. There was no evidence of problems, goals or interventions related to that status. Patient's medication list included Eliquis and the plan of care did not include bleeding risk problems goals or intervention. There was evidence of a physician order dated 10/28/25 for Bactrim 800-160 daily for 10 days for a UTI. There was no evidence of any problems, goals or interventions related to infection. Patient #4 - The medication profile included Eliquis daily. There was no evidence of problems, goals or interventions related to bleeding risk. Patient #6 - The medication profile included Aspirin daily as a blood thinner. There was no evidence of problems, goals, or interventions related to bleeding risk. Patient #10 - The medication profile included Eliquis daily. There was no evidence of problems, goals or interventions related to bleeding risk.

Upon patient record review, 1 of 14 (Patient #4) 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 #4 - The initial plan of care order dated 10/02/25, listed Tylenol 500mg - take 1-2 tablets every 6 hrs as needed. There was no evidence of a maximum acetaminophen daily dose listed.

Upon patient record review, 7 of 14 (Patient #1,2,3,6,8,9,14) 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 - The recertification assessment dated 11/21/25 documented that patient is incontinent of bowel and bladder. There is no evidence of incontinent supplies listed on the plan of care. Patient #2 - The nursing comprehensive assessment dated 08/15/25 as well as subsequent assessments, document that patient is incontinent of bowel and bladder. There is no evidence of incontinent supplies listed on the plan of care. Patient #3 - The medication profile showed patient is utilizing oxygen as needed. There is no evidence of an oxygen concentrator listed as a DME item on the plan of care. Patient #6 - The nursing comprehensive assessment dated 10/14/25 as well as subsequent assessments, document that patient is incontinent of bowel and bladder. There is no evidence of incontinent supplies listed on the plan of care. Patient #8 - The nursing comprehensive assessment dated 11/05/25 as well as subsequent assessments, document that patient is incontinent of bowel and bladder. There is no evidence of incontinent supplies listed on the plan of care. Patient # 9 - The nursing comprehensive assessment dated 10/09/25 as well as subsequent assessments, document that patient is incontinent of bowel and bladder. There is no evidence of incontinent supplies listed on the plan of care. Patient #14 - The medication profile showed patient is utilizing oxygen as needed. There is no evidence of an oxygen concentrator listed as a DME item on the plan of care.

Upon patient record review 1 of 14 (Patient #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 #10 - The aide plan of care noted aide frequencies for 2 visits per week. For the week of 11/03/25-11/09/25 the medical record only showed one visit completed on 11/05/25. The week of 11/11/25-11/17/25, the medical record showed only one visit completed on 11/14/25. There was no evidence of a change in order, or documentation for missed visit.

Upon patient client record review, 1 of 14 (Patient #2) 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 #2 - The medical record showed a start of care date for 08/15/25. The Election of Benefit form page 1 showed a start of care for 08/05/25 and that form was signed by the POA on 10/17/25. There was no evidence of a valid Election of Benefit.

Upon patient record review, 1 of 11 (Patient #1) 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: HHA POC dated 09.23.2022, has instructions to give the patient both a chair bath and a shower bath. This indicates aide would need to choose.