Every finding on record at Orangevale Hospice Care, Inc.

Upon patient record review 2 of 14 (Patient #5,7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 5: The patient was admitted on 11/25/25. The spiritual care comprehensive assessment was not completed until 12/01/25. The psychosocial comprehensive was completed 12/4/25. There is no evidence that assessment components were completed within 5 days. Patient 7: Patient was admitted on 12/22/25. There is no evidence that a spiritual comprehensive assessment was completed until 12/29/25.

Upon patient record review, 2 of 14 (Patient #2,7) 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: Current medication record dated 11/29/25 includes an order for ClearLax oral powder, order does not include diluent. Corrected on site, medication record updated. Patient 7: Current medication record dated 12/22/25 includes an order for Polyethylene glycol oral powder, order does not include diluent. Corrected on site, medication record updated.

Upon patient record review, 1 of 14 (Patient #7) 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 7: Patient admitted on 12/22/25. Bereavement risk assessment was not completed until 12/29/25.

Upon patient record review, 3 of 14 (Patient #4,9,10) 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 4: The POC dated 12/23/25 contains an order for Xarelto . There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 9: The POC dated 12/31/25 contains an order for Pradaxa . There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated Patient 10: The current POC dated 12/31/25 contains an order for Pradaxa and Clopidogrel. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated

Upon patient record review, 2 of 14 (Patient #2,7) 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: Current POC dated 12/31/25 includes an order for ClearLax oral powder, order does not include diluent. Corrected on site, POC updated. Patient 7: Current POC dated 12/29/25 includes an order for Polyethylene glycol oral powder, order does not include diluent. Corrected on site, POC updated.

Upon patient record review, 9 of 14 (Patient #1,2,4,5,6,7,8,9,10) 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 Patient1,2,4,5,6,7,8,9,10: Most recent POC does not include evidence of frequencies of all tasks to be completed by the Aide. Corrected on site, POC(s) updated.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient#1: Review of clinical record revealed signed consents, Election Of Benefits (EOB), and Certification of Illness (CTI) revealed patient was admitted to the hospice on 10/15/22. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Unclear if care was provided prior to consents being signed.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence of the appropriate documentation for release of confidential information. Patient#1: Review of clinical record revealed signed consents, Election Of Benefits (EOB), and Certification of Illness (CTI) revealed patient was admitted to the hospice on 10/15/22. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Unclear if care was provided prior to consents being signed.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient#1: Review of clinical record revealed signed consents, Election Of Benefits (EOB), and Certification of Illness (CTI) revealed patient was admitted to the hospice on 10/15/22. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Unclear if care was provided prior to consents being signed.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient#1: Review of clinical record revealed signed consents, Election Of Benefits (EOB), and Certification of Illness (CTI) revealed patient was admitted to the hospice on 10/15/22. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Unclear if care was provided prior to consents being signed.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 The medication profile included Levothyroxine 0.025 mg 1 tab po daily x 6 days. However, review of patient's medication bottle revealed Levothyroxine 0.025 mg 2 tabs po daily x 6 days, confirmed patient taking 2 tabs.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient#1: The patient was admitted in the 1st benefit period from 10/15/22-1/12/23. The date on the CTI for the 1st BP was 10/15/22 - 5/15/23.

Upon patient client record review, 1 of 5 (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: Review of clinical record revealed signed consents/Election Of Benefit (EOB) with an effective date of 10/15/22. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Unclear as to the admission date and if care was provided prior to the EOB/consents.

Upon patient client record review 3 of 5 (Patient #1,#2,#3) 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. Patient#1: Review of clinical record revealed signed consents, Election Of Benefits (EOB), and Certification of Illness (CTI) revealed patient was admitted to the hospice on 10/15/22. The patient was admitted in the 1st benefit period from 10/15/22-1/12/23. The date on the CTI for the 1st BP was 10/15/22 - 5/15/23. Review of Interdisciplinary Team Meeting (IDT) documentation dated 10/28/22, 11/11/22, 11/25/22, 12/9/22 and 12/23/22 had an admission date of 10/17/22. The initial MSW assessment note was dated 6/30/22, yet the note was signed and dated on 10/17/22. Patient #2: Review of signed consents and EOB revealed an admission date of 10/15/22. IDT meeting notes dated 10/28,11/11/22, 11/25/22, 12/9/22 and 12/23/22 indicated an admission date of 12/15/22. Patient #3: Review of signed consents, EOB and CTI revealed patient was admitted to the hospice on 12/9/22. Review of IDT comprehensive assessment documentation indicated patient was admitted on 9/27/22.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #9: The record lacked evidence the hospice verified employee was issued a Drug Enforcement Administration license to prescribe controlled substances at time of hire and time of renewal in accordance with specific state practice and requirements.