Every finding on record at Mbs Hospice Care Inc

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care In January 2025, there were several wildfires in Southern California. While the fires were not in the direct area of this Hospice’s home office, they did involve the service area. The northern most edge of the service area runs through Santa Clarita, along 139. The Southern most edge of the service area runs down to a point at San Clemente. The Eastern edge runs to Yuelipa, east of Riverside. The wildfires involved in the service area: Eaton, Riverside, Palisades, Bert, Hurst, Olivas, Lidia, Sunset, Sunswept, Kenneth, Kageff, Hughes, Laguna. There is no evidence in the emergency preparedness program, or in the patient medical records that the emergency preparedness program was activated during January 2025.

Upon patient record review, 5 of 14 (Patient #2,5,6,7,8) 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 2,6: Oxygen is listed on the medication list as a treatment. There is no evidence of this medication on the medication list. Patient 5: Medication list with medication: Insulin Aspart 100 units/mL solution for injection subcutaneous. Instructions read “per sliding scale.” There is no evidence of further instructions in the medication list. Patient 7: Medication list with medication: polyethylene glycol 3350/17g powder for solution. Instructions for medication are PRN, hold for loose stool. Give one scoop with 8oz liquid. There is no evidence of frequency instructions in the medication list. COS Patient 8: Medication list with medication: lidoderm5% transdermal patch. Instructions for this medication are Left hip PRN pain. There is no evidence of frequency, duration, on/off instructions for this medication in the medication list.

Upon patient record review, 3 of 14 (Patient #6,8,11) 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 6,8,11: There is no evidence of initial bereavement assessment documented in the medical record.

Upon patient record review, 1 of 14 (Patient #2) 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 2: Physician’s SN visit frequency order is weekly and 2PRN; written 3/5/25. There are documented SN visits on 4/5, 4/19, and 5/9/25. There is no evidence of SN visits made between these 3 dates. 4/19/25-5/9/25 = 20 days which is greater than 15 days to update the comprehensive assessment.

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 observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient 1: There is no evidence of SC note or signature, indicating participation, for IDG dated 5/28/25. COS Patient 8: There is no evidence of SC, MSW notes or signatures for 5/28/25 IDG. COS

Upon patient record review, 1 of 14 (Patient #3) 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: Fall incident report is documented 4/2/25 with fall occurring on same date. In the narrative section of this incident report, it states there was a visit made to assess patient. There is no evidence of documented RN visit in the medical record. There is an on-call log that documents the 3/26/25 fall. Additionally, a secure text message was shown to surveyor. It was reported to surveyor that the text message was received from the on-call nurse and was a summary of visit made. The text message was dated 3/26/25 however, no evidence in patient record of follow up by RN.

Upon patient record review, 1 of 14 (Patient #1) 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: Taking Xarelto 15mg by mouth daily. There is no evidence of bleeding plan of care with problems, goals, interventions. COS

Upon patient record review, 5 of 14 (Patient #2,5,6,7,8) 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 2,6: Oxygen is listed on the plan of care as a treatment. There is no evidence of this medication on the plan of care. Patient 5: Plan of care with medication: Insulin Aspart 100 units/mL solution for injection subcutaneous. Instructions read “per sliding scale.” There is no evidence of further instructions in the plan of care. Patient 7: Plan of care with medication: polyethylene glycol 3350/17g powder for solution. Instructions for medication are PRN, hold for loose stool. Give one scoop with 8oz liquid. There is no evidence of frequency instructions in the plan of care. COS Patient 8: Plan of care with medication: lidoderm5% transdermal patch. Instructions for this medication are Left hip PRN pain. There is no evidence of frequency, duration, on/off instructions for this medication in the plan of care.

Upon patient record review, 5 of 14 (Patient #1,6,8,9,10) 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 equipment and supply needs. Patient 1: During home visit, observed DME used. No evidence of this DME on the plan of care: high back reclining wheelchair; hoyer lift for transfers. Also observed DME no longer being used, remains on POC: urinal, shower chair, standard wheelchair. COS Patient 6: DME needs assessed on admission: geri chair/recliner; nebulizer; suction machine; oxygen concentrator and E-tank. There is no evidence of these DME on the plan of care. COS Patient 8: DME needs assessed on admission: hospital bed; overbed table; walker; wheelchair; nebulizer; suction machine; oxygen concentrator; e-tank. There is no evidence of these DME on the plan of care. COS Patient 9: During home visit, observed DME used. No evidence of this DME on the plan of care: hoyer lift for transfers. COS Patient 10: During home visit, observed DME used. No evidence of this DME on the plan of care: APP for hospital bed, overbed table, hoyer lift for transfers. COS

Upon client record review, 9 of 14 (Patient #1,2,3,4,5,6,7,9,10) 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: There is no evidence of RN note for review and revision to POC if needed for IDG dated 5/28/25. COS Patient 2: There is no evidence of IDG meetings documented in the medical record after 3/19/25. COS Patient 3: 2/25/25 IDG does not have evidence of RN signature, indicating participation. There was no evidence of paper sign-in sheet for this IDG. 4/16 and 4/30/25 IDGs do not have evidence of RN notes for review and revision to POC if needed. 5/18/25 IDG has evidence of only MSW note documented in medical record, despite being seen by RN, SC, and MSW. COS Patient 4: Most recent IDT documented in chart is dated 4/30/25. IDT dated 2/1/25 has no evidence of RN signature, indicating participation. There was no evidence of paper sign-in sheet for this IDG. Patient 5: The most recent documented IDG is dated 4/30/25. COS IDG dated 3/25/25 has no evidence of SC signature, indicating participation along with review and revision to POC if needed. There is no evidence of paper sign-in sheet for this IDG. Patient 6: Patient admitted 5/23/25. Scheduled IDG occurred on 5/28/25. There is no evidence of IDG documented in patient’s medical record. COS Patient 7: IDG dated 5/14/25 has only RN note documented in medical record, despite being seen by RN, SC, and MSW. Patient 9: Most recent IDG documented in the medical record is dated 4/16/25. COS IDG dated 4/16/25 has only RN note documented in medical record, despite being seen by RN, SC, and MSW. COS Patient 10: There is no evidence of RN note for review and revision to POC if needed documented in medical record for IDGs dated: 12/11, 12/26/24; 1/8, 1/22, 2/5, 2/19, 3/5, 3/19/25.

Upon client record review, 8 of 14 (Patient #1,2,3,4,5,6,9,10) 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 social work visit frequency order is monthly and 1PRN. There is no evidence of documented social work visits in the medical record after initial evaluation on 3/28/25. Patient 2: Physician’s SN visit frequency order is weekly and 2PRN; written 3/5/25. There are documented SN visits on 4/5, 4/19, and 5/9/25. There is no evidence of SN visits made between these 3 dates. There is also no evidence of documented missed visits in the medical record. 4/5/25-4/19/25 = 14 days. 4/19/25-5/9/25 = 20 days. Physician’s social work visit frequency order reads: for initial evaluation to determine visit frequency. Order written 3/5/25. Noted social work visits documented in the medical record: 3/7/25 (initial visit), 4/1, 5/3, 6/2/25. There is no evidence of physician’s order for the April, May, or June social work visits in the medical record. Patient 3: Physician’s SC visit frequency order reads, “Refer to SC for initial evaluation of spiritual needs. Initial evaluation within 5 days from SOC.” Documented SC visits: 3/1/25 (initial), 5/24/25. There is no evidence of physician’s order for 5/24/25 visit. Physician’s social work visit frequency order reads, “MSW to provide initial evaluation within 5 days for SOC for psychosocial, environmental, community, and financial status of patient.” Documented social work visits: 2/27/25 (initial), 3/21, 4/8, 5/12, 6/2/25. There is no evidence of physician’s order for the March, April, May, June visits in the medical record. Patient 4: Physician’s social work visit frequency order is every recert. There are documented routine visits on 3/12, 5/1, and 6/2/25. There is no evidence of a physician’s order for these visits in the medical record. Patient 5: Physician’s social work visit frequency order is monthly and 1PRN. Order written 3/25/25. There is no evidence of social work visit documented for April 2025. Patient 6: Physician’s SN visit frequency order is weekly and 3PRN. There is no evidence of SN visits documented in the medical record after admission date. Patient 9: Physician’s SC visit frequency order is monthly and 1PRN. There is no evidence of visit made January 2025. COS-missed visit note added during survey. Patient 10: Physician’s SC visit frequency order is monthly and 1PRN. There is no evidence of visits made in August or September 2024; January 2025.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 5: Physician’s order, dated 4/19/25, for speech therapy evaluation. Physician’s order, dated 4/24/25, for Wound Masters referral. There is no evidence in the medical record that these visits occurred. COS-communication notes added during survey after contact made with family.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement QAPI plan states: department managers and supervisors are responsible for providing leadership to ensure the communication and coordination of QAPI activities. Managers are responsible for initiating immediate corrective action if problems identified threaten the safety of patients or staff. Additionally, they are responsible for participating in QAPI committee when assigned and identifying opportunities for improvement through their daily interactions. Clinical and office personnel are responsible for participating in identifying opportunities for improvement through their daily contact with patients, physicians, and other employees. Staff may be requested to participate in the QAPI committee or specific team activities such as data collection, analysis, action planning, and implementation of new or improved processes as needed. QAPI meeting held 4/15/2025 for Quarter 1, 2025. Documented in the Performance Improvement Measures part of the meeting minutes, it is noted that for the chart audit review section, there is documented 1 chart reviewed for 100% compliance. It is noted that there are no satisfaction surveys documented. Pain measurement within 48 hours documented 100% compliance with “0 patients reported uncomfortable during first 48 hours.” Surveyor observed >3 active patients with pain plans of care during survey. These were all initiated at start of care. There is no documentation of the hand hygiene PIP or the notes submission PIP in this part of the minutes. PIP quarter 1 data documents the following: PIP 1 (hand hygiene) 1RN and 1LVN assessed for hand hygiene compliance with 2/2 non-compliance. No further documentation of hand hygiene evaluations. PIP 2 (notes submission) 9 notes submitted late after 5 days. This information contradicts the Performance improvement measures section, where it was documented that only one chart was audited.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 3: Patient has 2 documented fall incident reports in the medical record. The first incident report is dated 4/2/25, with the documented fall occurring 3/26/25. There is no evidence of documentation that this is a late entry into the medical record. Hospice’s Policy No. 4-017.2 Procedure 1D states that when an incident occurs, the individual discovering the incident will complete an incident report form within 24 hours of the incident.

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, 6 of 14 (Patient #1,4,5,6,9,10) 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. All COS: Patient 1: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; record bowel movements; 1-2 person transfer; change patient’s linens. Patient 4: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; 2-person transfer. Patient 5: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; 1-person transfer; record bowel movements; feeding assistance; change patient’s linen; provide patient with companionship. Patient 6: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; 1-person transfer; record bowel movements; change patient’s linen. There is no diet documented in this plan of care. Patient 9: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; 1-person transfer; record bowel movements; 2 bed rails up; meal prep breakfast, lunch, and dinner; change patient’s linen. Patient 10: Tasks on the aide plan of care without evidence of assigned frequencies: turn and reposition; 1-person transfer; record bowel movements; change patient’s linen; meal prep breakfast, lunch, and dinner. Further, the aide care plan states one side rail up while the poc states 2 side rails up, causing conflicting information.

Upon patient record review 5 of 14 (Patient #4,5,6,8,9) 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 4: Physician’s aide visit frequency order, written 2/1/25 is twice weekly. There are 3 documented aide visits every week, beginning the week of 2/10/25. Patient 5: Physician’s aide visit frequency order, written 3/25/25 is twice weekly. There is no evidence of aide visits made before 4/2/25. Patient 6: Physician’s aide visit frequency order is twice weekly. There is no evidence of aide visits documented in the medical record. COS Patient 8: Physician’s 5/21/25 aide visit frequency order is twice weekly. There is no evidence of documented aide visits in the medical record. COS-visits added during survey. Patient 9: Physician’s aide visit frequency order is 3 times weekly. During week of 12/29/24-1/4/25, there are 2 visits documented (12/29/24 and 1/3/25). COS-missed visit note added to medical record. During week of 1/5-1/11/25, there are 5 visits documented (1/6,1/7,1/9,1/11/25). The task: feeding assistance is not documented as completed on visit dates: 1/7,1/9,1/11/25. There is no evidence of documentation of why this task was not completed on these dates.

Upon patient record review 2 of 14 (Patient #3,4) 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. Patient 3: Aide supervisory visits documented 4/1/25 and 4/17/25. This is 16 days. Patient 4: Aide supervisory visits documented 4/1/25 and 4/17/25; 16 days apart.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is not evidence of oversight by governing body as evidenced by inaccuracies noted in QAPI program, lack of implementation for EPP, CTI's not being completed appropriately and timely by hospice physicians, and lack of patient care needs and coordination by IDG group. In addition, governing body is not ensuring Administrator is overseeing hospice operations as evidenced by these deficiencies.

Upon patient record review, 5 of 14 (Patient #2,3,5,9,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. All COS: Patient 2: CTI 4, dated 5/4/25 to 7/2/25, is blank. Patient 3: CTI 3, dated 5/26/25 to 7/24/25 has no evidence of physician’s narrative, signature/date, or verbal order in the medical record. Patient 5: CTI 6, dated 5/24/25 to 7/22/25 has no evidence of physician’s narrative, signature/date, or verbal order in the medical record. Patient 9: CTI 4, dated 5/1/25-6/29/25 has no evidence of physician’s narrative, signature/date, or verbal order in the medical record. Patient 10: CTI for certification period 5, dated 4/30/25, is blank.

Upon patient client record review, 1 of 14 (Patient #1) 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: EOB Addendum: Documentation states addendum was requested on 03/24/2025 and was provided to patient/family on 05/08/2025. There is no evidence of documentation re: why addendum was provided to patient/family late.

Upon patient record review, 2 of 5 (Patient #1,3) 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. Patient 1, 3: The chaplain performed the initial comprehensive assessment and established a regular visit frequency of once monthly. On 10.20.2021, the B&C representative called the SN to request no further SC visits. A communication note was entered, but the plan of care was not updated to discontinue the SC visits. Patient 3: The comprehensive initial nursing assessment indicates the patient has swallowing difficulty, and requires a pureed diet with nectar thickened liquids. All SN assessments of the patient indicate the patient requires assistance with feeding and has difficulty with chewing and/or swallowing. The medication list indicates the patient utilizes geritussin PRN for cough. The SN note dated 09.24.2021 states the patient is at a high risk for aspiration. However, there is no evidence of a care plan related to aspiration or swallowing safety. (corrected on site)

Upon patient record review and direct observation, 1 of 5 (Patient #3) did not have evidence the plan of care must included all equipment and supply needs. Patient 3: Patient has DuoNeb ordered for PRN use per the medication list, and is noted during several SN visits to utilize these treatments for SOB episodes. Patient was noted to have a nebulizer present in the B&C during the home visit. However, the nebulizer does not appear on the plan of care. (corrected on site)