Every finding on record at Nexus Hospice of the Inland Empire LLC

Upon patient record review, 1 of 6 (Patient #1) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: On the RN comprehensive assessment 3/27/25 there is no evidence that the RN took into consideration the imminence of death. Corrected on site.

Upon patient record review, 1 of 6 (Patient #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 equipment and supply needs. Patient 2: On the SN assessment 4/1/25 during the visit the nurse documented "suctioned patient" there is no order for suction machine on the plan of care.

Upon client record review, 1 of 6 (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: On the IDG 4/29/25 there is no evidence that the MD collaborated to review and revise POC as the MD did not sign the IDG note.

Upon patient record review, 2 of 6 (Patient #2,6) 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: There is no evidence in the RN comprehensive assessment on 4/1/25 that goals and interventions were created for the patient. There are no nursing goals or interventions on the POC. Patient 6: On the medication profile the patient is ordered Eliquis 5mg daily. There is no risk for bleeding with goals and interventions found on the POC.

Upon client record review, 2 of 6 (Patient #1, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On the POC 3/27/25 the frequency for the skilled nurse was indicated at 2x/week. The skilled nurse saw the patient three times in one week on 4/8/25, 4/10/25 and 4/12/25. The nurse documented in the visit note that it was a prn visit but marked the visit box for a scheduled visit. Patient 2: On the SN assessment 4/1/25 during the visit the nurse documented "suctioned patient" there is no order for suctioning to be performed. Patient 5: On 12/27/22 the skilled nurse made a scheduled visit to patient, there is no evidence of documentation of assessment or vital signs during the visit to show visit performed.

Upon patient record review, 5 of 6 (Patient #1,2,3,4,5) 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: The aide plan of care on 3/27/25 indicated for turn and reposition, record bowel movements, and feeding assistance as tolerated. There was no evidence of a frequency. Corrected on site Patient 2: The aide plan of care on 4/1/25 indicated for turn and reposition, record bowel movements, and change patient linens. There was no evidence of a frequency. Patient 3: The aide plan of care on 3/20/25 indicated for turn and reposition, record bowel movements, and change patient linens. There was no evidence of a frequency. Patient 4: The aide plan of care indicated for record bowel movements, encourage fluids as tolerated and change patient linens. There was no evidence of a frequency. Patient 5: The aide plan of care indicated for turn and reposition, encourage fluids as tolerated and change patient linens .There was no evidence of a frequency.

Upon patient record review 1 of 6 (Patient #1) 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: The visit frequency for the aide is ordered two times a week on 3/27/25, the aide visited the patient on 4/1/25 only for that week, there is no documentation of missed visits. Corrected on site.

Upon patient client record review, 1 of 6 (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: On the RN comprehensive assessment 4/1/25 the RN documented, "No history of patient attemptering to get our of bed" "Coughing up clear thick slutum", "educated family on skin breakdowm". There are multiple misspellings in the comprehensive assessment.

Upon client record review, 1 of 6 (Patient #6) 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 6: There is no evidence in the patient record that a copy of the hospice discharge summary was forwarded to the patient's attending physician.

Upon client record review, 1 of 6 (Patient #6) did not have evidence that the discharge summary includes all required information. Patient 6: There is no evidence in the patient record that the discharge summary on 10/22/22 contains a summary of the patient's stay, including treatments, symptoms and pain management, the patients plan of care and the latest physician orders. There is no discharge summary noted in the record.

Upon personnel record review, 1 of 13 (Personnel #10) 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 #10 Does not have evidence of an MSW degree in the personnel record. There is evidence of a Master's of psychology in the personnel record. There is no evidence that an MSW is supervising over Social Work.

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.

Upon patient record review, 1 of 5 (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. Patient 4: The medication profile contains Miralax 17gm po daily with no evidence of a diluent. Corrected on site.

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 medications and treatments. Patient 4: The POC contains Miralax 17gm po daily with no evidence of a diluent. Corrected on site.

Upon patient record review 2 of 4 applicable records (Patient #2,#3) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The POC contains an order for aide 2 times per week starting 8-17-21. The week of 8-15-21--8-21-21 there is evidence the aide made 1 visit on 8-20-21, there was no second visit made that week and there was no missed visit documentation. Patient 3: The POC contains an order for aide 2 times per week starting 12-15-21. The week of 12-12-21--12-18-21 there is evidence the aide made 1 visit that week on 12-16-21, there is no second visit made that week and no missed visit documentation.

Upon patient client record review, 1 of 5 (Patient #1) 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 1: There is evidence of a supervisory visit being made for the LPN and the Aide by the RN on 11-18-21, There is evidence that the Aide's first visit with the pt was 11-19-21 and the LVN's first visit with the pt was 11-20-21. There is no evidence that aide or the LVN saw the patient on or before 11-18-21.