Every finding on record at Nexus Hospice of the High Desert, LLC

Upon patient record review, 3 of 5 (Patient #1,5) 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, MD orders state: May apply A&D ointment to dry skin as needed for skin maintenance. May apply Calmoseptine to rash/redness as needed for skin maintenance. No evidence of where to apply on the skin on the medication list. Patient #5, Lorazepam 2mg/ml, 0.5mg/0.25ml every 4 hours as needed for anxiety/restlessness. Lorazepam 0.5mg 1 tablet every 6 hours, as needed, anxiety/restlessness. No evidence on the medication list when liquid would be used instead of pill form.

Upon patient record review, 4 of 5 (Patient #1,3,4,5) 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, No evidence of goals and interventions of care provided to patient under ADL care plan. No evidence of goals and interventions of oxygen directions under respiratory care plan. No evidence of goals and interventions of skin care or problem for skin integrity related to MD orders of: May apply A&D ointment to dry skin as needed for skin maintenance. May apply Calmoseptine to rash/redness as needed for skin maintenance. Patient #3,5, No evidence of goals and interventions of care provided to patient under ADL care plan. Patient #4, No evidence of goals and interventions for patient being a full code status.

Upon patient record review, 1 of 5 (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 equipment and supply needs. Patient #4, No evidence of E tank documented under DME on the plan of care. RN initial assessment documented on her note that patient had oxygen concentrator, E tank, nebulizer.

Upon patient record review, 1 of 5 (Patient #1) 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, No evidence of MD signature on IDG note dated 10/7/25 to support MD was present during IDG meeting.

Upon patient record review, 1 of 5 (Patient #2) 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 #2, Patient problem is infection/immunological documents; patient has UTI. Goal is for UTI to be resolved by end of antibiotic therapy. Intervention patient to complete course of antibiotics prescribed by MD. No evidence of updated care plan after completion of antibiotic. Nitrofurantoin start date 8/22/25, discontinued date 8/29/25.

Upon patient record review, 2 of 5 (Patient #4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, SN frequency 3x/week effective 8/28/25. Patient was seen 2x the first week on 8/28 and 8/29. No evidence frequency was followed of 3x/week. Patient #5, MSW frequency 1x/month and 3 PRN. No evidence of visits completed in June and August with documentation showing missed visits for 6/20/25 and 8/22/25. Both missed visits documentation stated patient/family were busy. No evidence of attempt to make visit on a different day of the month that works for patient/family.

Upon patient record review, 3 of 5 (Patient #1,4,5) 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, MD order states; may apply Calmoseptine to rash/redness as needed for skin maintenance. Aide may apply during care. No evidence this was included on the aide care plan to provide care. Patient #4,5, No evidence of high risk for diabetic medication documented on aide care plan

Upon patient record review 1 of 5 (Patient #5) 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 #5, RN supervisory visits were completed 6/20,7/3,7/18/25. Supervisory visit was completed at 15 days. No evidence of a supervisory visit completed every 14 days between 7/3 and 7/18/25.

Upon patient record review, 2 of 5 (Patient #2,3) 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, Election statement states election of benefit date 7/9/25, signed by patient on 7/23/25. Patient #3, Election statement states election of benefit date 6/25/25, signed by patient on 7/23/25.

Upon patient record review, 1 of 5 (Patient #2) 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 #2, MSW note dated 10/2/25, no evidence of note completion, or signature. Documentation was missing narrative.

Upon patient record review, 1 of 5 (Patient #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 #2: This patient is prescribed Acetaminophen ES 500mg every 6 hours as needed, Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed and Hydrocodone/ Acetaminophen 10/325 one tablet 4 times daily as needed. The medication list did not specify a 4000mg maximum dose of acetaminophen within 24 hours.

Upon patient record review, 1 of 5 (Patients #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 #2: This patient is prescribed Acetaminophen ES 500mg every 6 hours as needed, Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed and Hydrocodone/ Acetaminophen 10/325 one tablet 4 times daily as needed. The plan of care did not specify a 4000mg maximum dose of acetaminophen within 24 hours.

Upon patient record review, 11 of 14 (Patients #1, 2, 3, 4, 5, 8, 9, 10, 12, 13, 14) 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 Patients #1, 2, 3, 4, 5, 8, 9, 10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting. Patient #1: The medication profile listed Senna plus 8.6/50mg daily. It also listed Senna 8.6mg daily as well as Colace 50mg daily. This is duplication of medications. Patient #2: Medication profile listed Plavix and also Clopidogrel. These are the same medication leading to duplicate entry. Patients #12, 13, 14: There is no evidence in the records of a drug review being completed prior to the LVN visit.

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

Upon patient record review, 5 of 14 (Patient #8, 9, 12, 13, 14) 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 #8: Patient admitted 05/29/25. On LVN visit 06/05/25, patient found with BP of 159/101. Morning meds given per ALF staff. At end of visit, BP still elevated at 148/90. No evidence that these changes were reported to physician or case manager. No follow up phone call or visit for 4 days. On LVN visit 06/11/25, BP was 161/101 and temperature was 102.5. Documented that ALF staff gave morning meds and at end of visit, BP was 142/82, temperature was 100.2. No evidence that change in condition and abnormal vital signs reported to RN or physician. The next day, BP continued to be elevated at 178/96 without documentation of report to RN or physician. Also, LVN states "patient no longer getting out of bed and requiring to be fed, states patient only eating bites. No follow up phone call or visit for 4 days. Patient #9: on 05/23/25, LVN documents that patient experiencing notable ascites and jaundice. No follow up call or visit for 3 days. On 05/26/25, continued ascites and jaundice documented, LVN documents education provided on change in condition and overall decline. No follow up call or visit for 3 days. On 05/29/25 LVN documents that patient is now bedbound. On 05/30/25, PRN visit made by LVN as patient hard to arouse and wife crying and anxious. Patient having itching and has not had a BM in 4 days. Education provided on decline. No change in frequency, no follow up call or visit for 3 days. Patients 12,13,14: No evidence RN ensured continuous assessment as there was no comprehensive assessment of the patient and family's needs to coordinate activities with other members of the interdisciplinary group (IDG) completed prior to sending LVN to see patient.

Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 9, 12, 13, 14) 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: The patient has a nebulizer. There are no interventions and goals for nebulizer. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #2: The patient has heart disease with edema. She is on anticoagulants. She is taking promethazine for nausea. There are no interventions or goals for edema, education on anticoagulants or nausea. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #3: The patient has Senile degeneration of the brain. The patient takes loperamide for prn diarrhea. There are no interventions or goals for the primary hospice diagnosis or for diarrhea. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #4: There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #5: The patient is being treated for heartburn and constipation. There are no interventions or goals for heartburn and constipation. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #6: The patient per History and Physical is legally blind and the nursing assessments states patient lives in apartment alone. There are no interventions or goals for increased risks due to legally blind. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #9: Patient has Pancreatic cancer. The patient has reported jaundice, ascites, and itching. there are no interventions or goals for Jaundice, ascites, itching or pancreatic cancer. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patients 12, 13, 14: The record indicates that the LVN made a visit in which pain and symptom assessments along with vital signs obtained and medication education on morphine. There is no evidence of any POC established by RN/IDG team with problems, goals, or interventions prior to LVN visit.

Upon patient record review, 3 of 14 (Patient #12,13,14) 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. Patients #12, 13, 14: There is no evidence of a scope defined for LVN making visit prior to RN comprehensive assessment.

Upon patient record review, 2 of 14 (Patients #8, 9) 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 #8: On 06/16/25, the nurse documents that the patient is "transitioning" with changes in condition. There are no changes to plan of care regarding imminent death. Patient #9: The patient was documented as being "now bedbound" on 05/29/25 with changes in condition. There was no update to the plan of care including change in condition as well as imminent death.

Upon client record review, 3 of 14 (Patient #12, 13, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients #12, 13, 14: The record indicates that the LVN made a "tuck in" visit in which the LVN completed vital signs, pain and symptom assessments as well as providing medication education. There is no evidence of an order for the plan of care for this care.

Upon personnel record review, 1 of 12 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: The skills competency checklist states that tub bath, shower, nail and skin care, oral hygiene, as well as toileting and elimination were done verbally.

Upon personnel record review, 1 of 14 (Personnel # 9) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #9: The social worker has a Masters in Psychology and a Bachelors of Science in Human Services Management. There is no evidence of a Masters of Social work providing ongoing supervision as described in paragraph (b)(3)(i)(A) of CFR 418.114

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5: Did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. There is evidence of a box marked "condition is poor-rapidly declining". There is another box next to it that has imminently dying and it is left blank. There is no evidence of a statement that says whether patient is imminently dying or not.

Upon patient client record review, 1 of 5 (Patient #5) 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 5: In a Clinical Findings note the RN documents "Discharge patient from Sublime Hospice due to revocation from hospice." The hospice being surveyed is Nexus Hospice of the High Desert.