Every finding on record at Nosotros Hospice, Inc.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the hospice did not ensure that services were consistent with the interdisciplinary plan of care. CLINICAL RECORD 2: Clinical record review lacked evidence of supervision by the registered nurse to ensure that the nursing needs of the patient were met as identified in the patient's assessments. 10/21/2024 nursing assessment states “SN provided wound care to the sacrum, medication changed as of today PER MD, now to apply Medihoney to the wound bed; A named medical practice to further assess the wound and pending new orders. Patient tolerated well wound care, and will continue wound are three times weekly until further notice.” Order dated and signed on 10/14/2025 MD update/summary: Multiple lesions to arms, hands, legs, and exposed skin to the torso/change in medication to sacral wound, Order: Sn to provide wound care to sacrum three times weekly using aseptic technique, cleanse with normal saline/wound cleaner, pat dry gently apply small amount of Medihoney to wound bed cover with sacral foam dressing. Caregiver to perform wound care when SN is not available. SN to instruct, assess, or observe for performance of proper wound care. SN to discontinue wound care and all associated treatment when healed. Caregiver to apply bacitracin ointment over affected areas/the lesions on the body twice daily until clear. Caregiver to provide good hygiene to the patient daily and as needed. GOAL: skin dry, scabbed, scaly lesions to clear, and the sacrum to stay free from infections and without complications. 10/23/2024 LVN nursing assessment stated “Sacral wound treatment cleansed with wound cleanser, pat dry; packed with Iodoform gauze tunneled area—Applied Silvadene cream with alginate to the base of the wound and secured with Mepilex. Right great toe wound treatment: cleansed the right great toe with normal saline, patted dry; applied Medihoney to the wound bed, covered with clean 4x4 gauze, and taped down with tape to secure. The wound care and treatments provided by the LVN were not included in the interdisciplinary plan of care and physician orders. During an interview with the Administrator on 07/16/2025, she verified that the LVN did not follow the physician's orders and the plan of care. She stated that they are providing additional education to clinical staff regarding care plans. She also stated that they had self-identified this issue and had been working on it since February 2025.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the hospice did not ensure that services were consistent with the interdisciplinary plan of care. CLINICAL RECORD 2: Clinical record review lacked evidence of supervision by the registered nurse to ensure that the nursing needs of the patient were met as identified in the patient's assessments. 10/21/2024 nursing assessment states “SN provided wound care to the sacrum, medication changed as of today PER MD, now to apply Medihoney to the wound bed; A named medical practice to further assess the wound and pending new orders. Patient tolerated well wound care, and will continue wound are three times weekly until further notice.” Order dated and signed on 10/14/2025 MD update/summary: Multiple lesions to arms, hands, legs, and exposed skin to the torso/change in medication to sacral wound, Order: Sn to provide wound care to sacrum three times weekly using aseptic technique, cleanse with normal saline/wound cleaner, pat dry gently apply small amount of Medihoney to wound bed cover with sacral foam dressing. Caregiver to perform wound care when SN is not available. SN to instruct, assess, or observe for performance of proper wound care. SN to discontinue wound care and all associated treatment when healed. Caregiver to apply bacitracin ointment over affected areas/the lesions on the body twice daily until clear. Caregiver to provide good hygiene to the patient daily and as needed. GOAL: skin dry, scabbed, scaly lesions to clear, and the sacrum to stay free from infections and without complications. 10/23/2024 LVN nursing assessment stated “Sacral wound treatment cleansed with wound cleanser, pat dry; packed with Iodoform gauze tunneled area—Applied Silvadene cream with alginate to the base of the wound and secured with Mepilex. Right great toe wound treatment: cleansed the right great toe with normal saline, patted dry; applied Medihoney to the wound bed, covered with clean 4x4 gauze, and taped down with tape to secure. The wound care and treatments provided by the LVN were not included in the interdisciplinary plan of care and physician orders. During an interview with the Administrator on 07/16/2025, she verified that the LVN did not follow the physician's orders and the plan of care. She stated that they are providing additional education to clinical staff regarding care plans. She also stated that they had self-identified this issue and had been working on it since February 2025.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed that included the provision of aide services, the agency did not ensure aide services were provided as ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 5: The hospice plan of care dated 06/14/2023 included an order for hospice aide visit frequency three times per week. The hospice aide care plan dated 06/14/2023 created by the Registered Nurse assigned shampoo every Monday. The hospice aide visit notes dated 06/15/2023 (Thursday) and 07/07/2023 (Friday) included documentation that the aide provided shampoo hair at each visit and did not follow the aide care plan which assigned shampoo every Monday. During an interview on 07/17/2023, the Administrator reviewed the associated record and stated the aide did not follow care plan as ordered.

It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by clinical records review and interview. 1 of 13 (8%) clinical records reviewed revealed the agency did not ensure the patient had the right to choose the attending physician.. Record # 8 was reviewed and identified the patient elected hospice care on 11/8/2021 with a primary diagnosis of senile degeneration of the brain. Review of the record revealed the Informed Consent/Election of Hospice statement signed by the patient's caregiver on 11/8/2021 did not include evidence the patient had the right to choose the attending physician, or evidence the patient acknowledged the medical director was chosen as the attending physician. During an interview on 9/20/202, the Director of Clinical Services (Staff #2) agreed the patient right to choose an attending physician was not evident on the Informed Consent/Election of Hospice statements.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed it was revealed the agency did not ensure the plan of care was updated to include hospice care and services with specific needs identified in the comprehensive assessment. . Clinical Record # 11 was reviewed and identified the patient elected hospice care on 9/9/2022 with a primary diagnosis of COPD. The RN documented in the comprehensive assessment on 9/9/2022 that "the patient has 3+ bilateral lower extremity edema with discolored toes." The initial plan of care order dated 9/9/2022 and updated plan of care order dated 9/15/2022 did not include problems, interventions and goals related to bilateral lower extremity edema with discolored toes. During an interview on 9/20/2022, the Director of Clinical Services (Staff # 5) confirmed that the plan of care was not updated to include hospice care problems, interventions and goals related to bilateral lower extremity edema with discolored toes.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 13 (8%) plans of care in clinical records reviewed revealed the agency did not ensure that a written plan of care specified the drugs and treatments necessary to meet the patient's needs. Record #2 was reviewed and identified the patient elected hospice care on 8/12/2022. During a home observation visit with the Hospice Aide (Staff #2) on 9/20/2022 stated she has provided treatments to the patient during her visits since admission on 8/12/2022. She described her treatment as an application of Ammonium Lactate 12% to the patient's bilateral lower legs and feet for dry skin, hydrocortisone cream 1% at the patient's request, on "itchy" areas, and Aspercreme lidocaine at the patient's request to the patient's back for back pain. The comprehensive assessment and the aide plan of care dated 8/12/2022 did not include these medications and skin care treatment. During an interview on 9/20/2022 the Director of Clinical Services (Staff # 5) confirmed these drugs/treatments Ammonium Lactate 12%, hydrocortisone cream 1%, and Aspercreme lidocaine were not included in the plan of care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 1 (100%) observation visit with a hospice aide revealed the agency did not ensure the aide services provided were conistent with the Interdisciplinary Group orders and the plan of care. Home Visit# 2 - During an observation visit with the hospice aide (staff #2) on 9/20/2022 with patient #2 elected the hospice benefit on 8/12/2022 with a primary diagnosis of Parkinson's Disease. The aide showed this surveyor 3 topical creams, hydrocortisone cream 1%, Aspercreme lidocaine and Aspercreme lidocaine that the hospice aide applied to the patient during each hospice aide visit since admission on 8/12/2022. The aide stated she applies this cream during each visit.The aide plan of care effective 8/12/2022 did not contain the 3 topical creams the aide applied to the patient and skin care was not assigned as a service. Interview #2 during an interview on 9/20/2022 the Director of Clinical Services agreed the hospice aide was providing services that were not ordered in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 1 (100%) observation visits completed with a hospice aide was revealed the agency did not ensure hospice aides reported patient changes related to the plan of care. changes in the patient's needs were reported from the hospice aide to the registered nurse, and the agency did not ensure the aide documented changes of the patient's needs in the clinical record. Home Visit 2 - During an observation visit with the hospice aide (staff #2) on 9/20/2022 the aide showed this surveyor 3 topical creams that the hospice aide applies to the patient (record #2) who elected the hospice benefit on 8/12/2022 with a primary diagnosis of Parkinson's Disease, during each hospice aide visit since admission on 8/12/2022. The aide stated she applies Ammonium Lactate 12% to the patient's bilateral lower legs and feet for dry skin, hydrocortisone cream 1% at the patient's request, on "itchy" areas, and Aspercreme lidocaine at the patient's request to the patient's back for back pain. Review of the aide plan of care dated 8/12/2022 revealed the application of the 3 topical creams the aide is applying to the patient are not assigned on the aide plan of care. During the observation visit on 9/20/2022 the hospice aide stated there has been no verbal communication of the variances with the Interdisciplinary Group. There was no documented evidence that the Interdisciplinary Group was made aware of the variances and skin care needs. Interview #2 during an interview on 9/20/2022 the Director of Clinical Services confirmed the creams the aide is applying to the patient are not in the plan of care and stated she was not aware of the need for these additional services provided by the hospice aide and will educate the aides and registered nurses on the requirement to report changes to the Interdisciplinary Group and document changes in the clinical records.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed that the organization did not ensure accuracy and completion of the Informed Consent/Election of Hospice statement for the episode reviewed. Record # 4 was reviewed and identified the patient elected hospice care on 12/17/2021 with a primary diagnosis of unspecified protein-calorie malnutrition. The patient clinical record, electronic or paper copies, did not include admission documentation identifying the name of the hospice the patient was electing to receive hospice services. Review of the Informed Consent/Election of Hospice statement signed by the patient on 12/17/2021 revealed it was not completed correctly as evidenced by not identifying the name of the hospice the patient was electing to receive hospice services. During an interview and joint record review on 9/20/2022, the Director of Clinical Services reviewed the Informed Consent/Election of Hospice statement and verified the name of the hospice was not included on the statement.