Every finding on record at Pacific Hospice and Palliative Care, LLC

Upon patient record review 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5, No evidence of MSW initial assessment, marked as missed visit. No evidence the RN completed the psychosocial assessment.

Upon patient record review, 3 of 14 (Patient #3,4,5) 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 #3,4,5, No evidence of bereavement assessment completed within the first 5 days.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #7, No evidence of RN assessment on 7/8/25 as visit was marked missed visit. RN visits made on 6/23/25 and 7/16/25.

Upon patient record review, 7 of 14 (Patient #1,2,6,7,8,9,10) 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 condition. Patient #1, No evidence of problems/goals/interventions for psychosocial care plan addressing patient having a full code. No evidence of problems/goals/interventions for aide personal care being provided. Patient #2, No evidence of problems/goals/interventions for high risk medication, Eliquis. No evidence of problems/goals/interventions for aide personal care being provided. Patient #6, No evidence of care plan with problems/goals/interventions for pain identified in the record. Patient has orders for acetaminophen 500mg 2x/day as needed for mild pain, Ibuprofen 400mg 3x/day as needed with no problems/goals/interventions listed. Patient 7,8,9,10, No evidence of problems/goals/interventions for aide personal care being provided.

Upon patient record review, 1 of 14 (Patient #4) 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. Patient #4, MSW frequency 2 PRN, start 9/5/25 ends 10/31/25. No evidence of a frequency.

Upon patient record review, 3 of 14 (Patient #3,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3, SC frequency 1m2. No evidence of SC visit in May 2025. Patient #7, SC frequency 1m3. Patient seen twice on 5/8/25 and 5/16/25 within the same month. Patient #8, SC frequency 1m2. Patient seen twice in August and September on the following dates: 8/8/25, 8/20/25, 9/3/25, 9/17/25.

Upon observation and home visit, 1 of 3 (Patient #3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient#3, RN removed gloves, entered her bag without hand sanitizing then reapplied a new pair of gloves without hand sanitizing before placing new pair of gloves on.

Upon patient record review 1 of 14 (Patient #7) 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 #7, No evidence of aide supervisory visit on 7/8/25, as visit was marked missed. Aide supervisory was completed on 6/23/25 then 7/16/25 which is greater than 14 days.

Upon patient record review, 3 of 14 (Patient #5,6,8) 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 #5,6,8, No evidence of clinical information documented in the narrative on the CTI.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11,12, No evidence of discharge summary of the patient's stay, including treatments, symptoms and pain management. No evidence of documentation of post-discharge continuity of care.

Upon patient record review, 2 of 5 (Patient #1, #3) 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 RN comprehensive assessment on 11/11/2022 stated patient is confused, anxious, restless, dependent on walker, has shower chair, and is incontinent of urine. There was no plan of care with goals and interventions in the plan of care related to neurological problems, mobility and safety issues identified; or urinary incontinence. Also, the MSW was ordered 1xmonthly and there were no goals or interventions in the plan of care related to any psychosocial needs or care being provided. Patient #3: The medication profile included Metformin HCL 500mg BID. There was no evidence of endocrine problems, goals, or interventions included in the plan of care. Also, the medication profile included Atorvastatin 80 mg at HS and Lisinopril 10mg every day. There was no evidence of cardiovascular problems, goals, or interventions included in the plan of care. Additionally the social worker and chaplain were ordered 1xmonth and there was no plan of care addressing any psychosocial or spiritual care issues, goals, or interventions.

Upon patient record review, 3 of 5 (Patient #1, #2, #3) 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 #1: The RN comprehensive assessment stated patient was dependent on walker and has a shower chair. There was no evidence of shower chair or walker being addressed in the plan of care. Patient #2: The RN comprehensive assessment stated patient has a shower chair. There was no evidence of shower chair addressed in the plan of care. Patient #3: The RN comprehensive assessment stated patient has a shower chair. There was no evidence of shower chair addressed in the plan of care.

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: The RN comprehensive assessment was completed on 11/1/2022 upon admission. The RN signed and dated the RN comprehensive assessment 10-25-2022.