Every finding on record at Nayar Hospice LLC

Upon patient record review, 2 of 14 (Patient #5,10) did not contain evidence that a Registered Nurse had been 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 #5: An Incident Report was documented on 04/20/25, as received from an in-home family/caregiver, reporting that the patient had fallen from bed 2x the previous evening. The Incident Report did not contain documented evidence that the Physician had been notified. However, a verbal order was obtained from the Physician on 04/20/25 for an additional nursing visit that day. The nurse documented on that visit that the fall had resulted in: 1) A 1cm laceration to right wrist; 2) A bruised lump on the right forehead; and 3) Pain and swelling in the right toes. The nurse documented an intervention of "ice to the toes". The next (04/25/25) subsequent SN visit was documented as, "Patient has had a fall with no injuries." The next IDG Meeting 04/30/25 noted, "The patient had had a fall." It is not evident as to whether the nurse making the 04/20/25 visit had followed up and reported the status of the laceration to right wrist, nor if any treatment orders, if any, having been obtained from the Medical Director. Nor was there evidence that the status of the right foot painful/swollen toes were followed up on at the next SN visit. Patient #10: SOC 04/21/25- The hospital (cardiac admission) referral did mention a scalp laceration, but without any treatment details. There was nothing documented on the RN SOC visit regarding an assessment of such scalp laceration. On 04/22/25 the RN Case Manager made a visit, and documented that, "The patient has dissolvable scalp stitches". No description of that site was documented, nor of any treatment done.

Upon patient record review, 9 of 14 (Patients #2, 3, 4, 5, 6, 7, 8, 9, 10) did not contain evidence that the Hospice had 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, and pertinent information, necessary for the palliation and management of the terminal illness and related conditions: Patients #2, 3, 4, 5, 6, 8, and 9: Were identified elsewhere in the clinical record as having a DNR status. However, this Advance Directive status was not included on their Plan(s) of Care. Patient #7: Was identified elsewhere in the clinical record as being a Full Code status. However, this was not included on the Plan of Care. Patient #10: The section of the Plan of Care intended for Advance Directives, or the absence of such, had been left blank,

Upon patient record review, 3 of 14 (Patients #2, 3, and 9) did not contain evidence that the Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of all services necessary to meet the specific patient and family needs: Patient #2: The IDG POC dated 05/14/25 included, "Spiritual Counselor p.r.n. (5) visits, and Social Worker p.r.n. (5) visits; without a Physician-ordered visit frequency for either discipline. Patient #3: The IDG POC dated 05/14/25 included, "Spiritual Counselor p.r.n. (5) visits"; without a Physician-ordered visit frequency. Patient #9: The IDG POC dated 05/14/25 included, "Spiritual Counselor p.r.n. (5) visits"; without a Physician-ordered visit frequency.

Upon patient record review, 1 of 14 (Patient #3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #3: The 05/14/25 IDG POC, medication section, listed: 1) "Oxygen NC p.r.n. daily", without a liter-per-minute dose. The RN Case Manager reported 2 lpm; and 2) "Change catheter on 05/16/25", without any detail to support that the patient has a supra-pubic urinary catheter in place.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment: Patient #10: SOC 04/21/25. The hospital (cardiac admission) referral did mention a scalp laceration, but without any treatment details. There was nothing documented on the RN SOC visit regarding an assessment of such scalp laceration. On 04/22/25 the RN Case Manager made a visit, and documented that, "The patient has dissolvable scalp stitches". No description of that site was documented, nor of any treatment done. The IDG POC dated 05/14/25 continued to include, "Patient has stitches left side of scalp due to fall." The Clinical Manager spoke with the RN Case Manager, who states that this entry should no longer be on the IDG POC.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: The 05/14/25 IDG POC included, "Effective 04/06/25. Bruised left leg. Maximum (3) stitches at each area of lateral left leg. Cleanse with wound cleanser, apply Medi-honey, apply non-adhesive dressing, then tape. Complete 2x weekly. Daughter to do (1) day and Hospice Nurse to do other visit day." SNV reports were reviewed for April 7, 14, 17, 21, 29 and May 6, 16, and 19. There was no documentation on any of those visits that the above wound care had been completed as ordered. The RN Case Manager reported that she had removed the stitches as per order. However, reported having never received, nor provided, any wound care.

Upon patient record review, 2 of 14 (Patients #1 and 2) did not contain evidence that Hospice Aide assignments and duties were: • 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 • There is evidence in the patient record that the Aide Plan of Care indicates 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: The 05/14/25 Aide POC assigned the following duties: 1) Chair bath; 2) Tub bath; and 3) Bed bath every visit. There was no documented evidence that the patient/caregiver was cognitively and functionally capable of making this bath type decision. In addition, the Aide POC established 05/14/25 assigned the Aide to ambulate patient every visit, if patient is able. There was no documented evidence that the patient/caregiver was cognitively and functionally capable of making this decision. On 05/15/25 the Aide documented that she had ambulated the patient. However, the RN Case Manager confirmed that the patient had remained bed-bound at that date. Patient #2: The 04/21/25 Aide POC assigned the following duties: 1) Chair bath; 2) Tub bath; and 3) Bed bath every visit. There was no documented evidence that the the patient/caregiver was cognitively and functionally capable of making this bath type decision.

Upon patient record review 2 of 14 (Patients #1 and 2) did not contain documented evidence that the Hospice Aide had provides services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #1: The Aide POC assigned the Aide to report a BM greater than 5 days. This section of the Aide home visit report 05/15/25 for this assigned task had been 'checked', but no date of last BM entered. Patient #2: The Aide POC assigned the Aide to report a BM greater than 5 days. This section of the Aide home visit report 05/19/25 for this assigned task had been 'checked', but no date of last BM entered.

Upon patient record review, 2 of 14 (Patients #11 and 12) did not contain a Discharge Summary which included all CMS-required content: Patient #11: Revocation. The DC Summary did not contain: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders Patient #12: No longer terminally ill. The DC Summary did not contain: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon patient record review, 2 of 12 (Patient # 8, 9) 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 #8 - There is documentation that the patient was using oxygen. Oxygen therapy was not included in medication profile. (corrected on site) Patient #9 - There is documentation that the patient was using oxygen. Oxygen therapy was not included in medication profile. (corrected on site)

Upon patient record review, 2 of 12 (Patient #8, 9) 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 #8 - The record indicated the patient had oxygen in the home. There was no evidence of an order for the oxygen. (corrected on site) Patient #9 - The record indicated the patient had oxygen in the home. There was no evidence of an order for the oxygen. (corrected on site)

Upon client record review, 1 of 12 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 -order dated 1/11/22 for SC 2x month. No evidence of second SC visit in February or March or refusal of visits. (corrected on site)

Upon patient record review 1 of 12 (Patient #1) 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 #1 - On visit of 3/17/22 the documentation states Patient not sleeping well and would like a sleep aid. RN will reach out to NP, " Visit on 3/21/22 states" Pt does not sleep well at night. Granddaughter is worried if she takes sleep medication, it will make her too drowsy. RN will discuss options with MD." 3/24/22 Summary states "Patient state she would like to try Melatonin to help her sleep at night. RN to tell granddaughter." No follow up reflected in documentation.

Upon patient record review 3 of 7 applicable (Patient #4) 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 - Aide assignment sheets states prepare meals 2xweek, tidy patient area 2xweek, patient/family emotional support 2 times/week. These were not checked off as being completed on visit of 3/25/22. (corrected on site) visit orders for aide were 1x week. No visit noted for week of 3/13/22- 3/20/22 nor missed visit note. (Corrected on site) Patient #5 - visit orders for aide were 1 x week starting 3/7/22. Aide went 2 times/week week of 3/21/22. (Corrected on site with new orders) Patient #7 - visit orders for aide were 3 x week starting 1/26/22. Missing visits noted on 2/25/22, 2/28/22, 3/11/22, 3/18/22. (Corrected on site)

Upon personnel record review, 3 of 6 applicable (Personnel #9, 10, 11) 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 #9, #10, and #11 - no evidence of competencies being completed during orientation.

Upon client record review, 1 of 1 applicable (Patient #3) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #3 - No evidence of transfer summary completion in record. (Corrected on site)