Every finding on record at Pure Bliss Hospice Care, Inc

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: SOC 06/19/25. The EOB was signed/dated on 06/19/25. However, the statement's content did not include: • Identification of an Attending Physician, if any. The individual or representative must acknowledge the identified Attending Physician was his or her choice. The DPCS reported that an admitting RN Case Manager had used an old form.

Upon observation and record review, 4 of 5 (Patients #1, 2, 3, and 4) did not contain documented evidence that the Hospice has an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the Hospice patients and families facing terminal illness and bereavement. Interdisciplinary Group members must provide the care and services offered by the Hospice, and the group, in its entirety, must oversee/supervise the care and services: Patient #1: The IDG meetings dated 08/08, 08/20, 09/03, and 09/17/25 did not have documentation of the Chaplain/Bereavement team member's participation in these meetings. The IDG in its entirety did not consistently oversee/supervise the care and services provided. Patient #2: The IDG meetings dated 07/01, 07/09, 07/23, 08/06, and 08/20/25 did not have documentation of the participation of all team members: 1) 07/01 no SW; 2) 07/09 no SW; 3) 07/23 no SW; 4) 08/06 no Chaplain; and 5) 08/20 no Chaplain. The IDG in its entirety did not consistently oversee/supervise the care and services provided. Patient #3: The IDG meetings dated 08/26, 09/03, and 09/17/25 did not have documentation of the participation of all team members. There was no Chaplain participation in any of these meetings. The IDG in its entirety did not consistently oversee/supervise the care and services provided. Patient #4: The IDG meetings dated 08/06, 08/20, 09/03, and 09/17/25 did not have documentation of the participation of all team members. There was no Chaplain participation in any of these meetings. The IDG in its entirety did not consistently oversee/supervise the care and services provided.

Upon patient record review, 2 of 5 (Patients #2 and 5) did not contain evidence that each patient record contains: An Election of Hospice Benefit Statement (EOB), completed in accordance with CMS requirement: Patient #2: SOC 07/01/25. The EOB was signed/dated on 07/01/25. However, the statement's content did not include: • Identification of the particular Hospice that will provide care to the individual; and • The 'effective date' of the election, which may be the first day of Hospice care or a later date, but may be no earlier than the date of the election was signed/dated. Anindividual may not designate an effective date that is retroactive. Patient #5: SOC 06/19/25. The EOB was signed/dated on 06/19/25. However, the statement's content did not include: • Identification of the particular Hospice that will provide care to the individual; • The 'effective date' of the election, which may be the first day of Hospice care or a later date, but may be no earlier than the date of the election was signed/dated. An individual may not designate an effective date that is retroactive. • Identification of an Attending Physician, if any. The individual or representative must acknowledge the identified Attending Physician was his or her choice. The DPCS reported that an admitting RN Case Manager had used an old form.

Upon patient record review, 1 of 15 (Patient #13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #13: Election of Medicare Hospice Benefit – No physician chosen by the patient. Section left blank. Dr. Proffett listed on face sheet as both MD’s.

Upon patient record review 6 of 15 (Patient #7, 8 10, 11, 13, 14) 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 #7: MSW initial assessment completed late on 11/10 Patient #8: SC initial assessment completed late on 12/14. Patient #10: SC initial assessment completed late on 12/9 Patient #11: MSW initial assessment completed late on 11/3 Patient #13: MSW initial assessment completed late on 10/28 Patient #14: MSW initial assessment completed late on 11/21

Upon patient record review, 3 of 15 (Patient #1, 7, 8) 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: Medication profile listed Cefpodxime 200 MG oral. Wrong route listed. Patient is NPO and all meds are giver per tube. oxygen not listed as medication. Records indicate that patient is on continuous oxygen via trach. Patient #7: Medication profile lists Systane opthmalic solution 1-2 drops PRN for dry eyes. Order doesn’t specify which or both eyes. Patient #8: Medication profile lists Albuterol sulfate inhalation. No delivery mechanism listed. Combigan ophthalmic 1 drop every 12 hours. No location listed

Upon patient record review, 1 of 15 (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: Initial Bereavement assessment completed late on 11/6

Upon patient record review, 3 of 15 (Patient #5, 6, 7) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #5: Initial POC didn't list disaster triage or mental status. Patient #6: Initial POC didn't list disaster triage or mental status. Patient #7: Initial POC didn't list disaster triage or mental status.

Upon patient record review, 3 of 15 (Patient #7, 8, 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. Patient #7:. POC ordered MSW 1x then PRN without evidence of specifics for PRN visits. COS Patient #8: "MSW 1, 1 prn" Frequency incomplete. Patient #14: POC ordered "MSW 1, 1 prn". Frequency incomplete.

Upon patient record review, 3 of 15 (Patient #1,7,8) 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 #1: Plan of care lists Sodium Chloride 0.9% solution for inhalation 5ml PRN. No indication or delivery mechanism listed. Albuterol solution 1 vial inhalation every 4 hours as needed. No indication or delivery system listed. In addition, POC listed Cefpodxime 200 MG oral. Wrong route listed. Patient is NPO and all meds are giver per tube. Patient #7: POC lists Systane opthmalic solution 1-2 drops PRN for dry eyes. Order doesn’t specify which or both eyes. Patient #8: POC lists Albuterol sulfate inhalation. No delivery mechanism listed. Combigan ophthalmic 1 drop every 12 hours. No location listed

Upon patient record review, 5 of 15 (Patient #1, 2, 3, 7, 10) 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: Initial POC - DME doesn’t list hospital bed, oxygen concentrator or ventilator. Records indicate that patient is on a ventilator. Patient #2: Initial POC didn't list wound and incontinence supplies. Records indicated that patient has sacral wound and is incontinent of bowel and bladder. Patient #3: Initial POC didn't list patient DME - wheelchair, hospital bed, or incontinence supplies. Records indicated that patient is incontinent and has wheelchair and hospital bed. Patient #7:. Initial POC didn't list DME - oxygen concentrator or supplies. Records indicated patient is incontinent and on oxygen Patient #10: Initial POC didn't list DME - records indicated patient has wheelchair and hospital bed or supplies. Records indicated patient is incontinent.

Upon client record review, 8 of 15 (Patient #1, 3, 4, 5, 6, 8, 9, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: POC dated 11/1 ordered MSW at initial and then at recert. Visit made on 12/29. No evidence of an order for the extra MSW visit. COS Patient #3: POC dated 12/1 lists RN 1xwk and SN1xwk. Unclear frequency. COS Patient #4: : POC summary lists RN 1xwk and SN1xwk. Unclear frequency. SC ordered initial and at recert. Extra visit on 12/8 No evidence of an order for the extra SC visit. COS Patient #5: POC frequency ordered SC at initial then 1xmo. SC visit on 12/4 and 12/8. No evidence of an order for the extra visit. COS Patient #6: POC ordered SC 1xmo. Extra visit on 11/29. No evidence of an order for the extra visit. RN ordered 1xwk. 2 visits wk of 11/19. No evidence of an order for the extra visit. COS Patient #8: No order for SC on POC. SC visit made on 12/8 and 12/14. No evidence of an order for the visits. LVN ordered 1xwk. No evidence of a visit wk of 12/17. RN ordered 1 every 2 wks. RN made extra visit on 12/22 (seen 12/18) No evidence of an order for the extra visit. Patient #9: Records indicate that 2 LVN visits were made the wk of 12/3 on 12/5 and 12/6. No evidence of an order for the extra LVN visit. Records indicate that an extra RN visit was made on 12/1. Previous visit on 11/27. No evidence of an order for the extra RN visit. No LVN or RN visits were marked as PRN Patient #11: POC ordered MSW monthly and 1 prn. No evidence of an MSW visit being made in the month of November

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: During the home visit, the RN did not have handwashing supplies with her and used patients soap and kleenix to dry hands as no papertowels available. No barrier used prior to setting down equipment on surfaces. No clear clean/dirty side on her equipment pouch. RN didn't have anything with her to clean equipment in the home, she cleans everything at the car but puts dirty equipment in pouch that also holds the equipment when clean. No evidence that pouch is properly cleaned with each use. Patient #2: During the home visit, the nurse put her cleaned vital sign equipment back down on the dirty work surface/barrier.

Upon patient record review, 2 of 15 (Patient #7, 13) 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 #7:. POC ordered aide 2xwk. Records indicated only one visit wk of 11/1 on 11/3. Patient #13: POC ordered aide 2xwk. Records indicated only one visit wk of 10/23 on 10/27

Upon patient record review, 1 of 15 (Patient #8) 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 #8: No evidence of an RN supervisory visit during the RN visit on 12/18. More than 14 days passed from prior to supervisory visit to the next one.

Upon patient client record review, 1 of 15 (Patient #13) 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 #13: Election of Medicare Hospice Benefit – No physician chosen by the patient. Section left blank. Dr. Proffett listed on face sheet as both MD’s.

Upon patient client record review, 4 of 15 (Patient #1, 6, 9, 14) 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: Page 2 of the Consent of Treatment/Acknowledgement/Financial Responsibility form incomplete. Section 10 "Financial Responsibility" was left blank. Patient #6: Addendum to election of hospice benefit form - both "I elect to receive" and "I decline" were marked. Unclear which is correct. Records indicate that the information was sent to patient. Patient #9: Consents for hospice care signed by patient but not signed by staff, Addendum not signed at all, Patient Acknowledgement not signed or filled out. Patient #14: Page 2 of the Consent of Treatment/Acknowledgement/Financial Responsibility form incomplete. Section 10 "Financial Responsibility" left blank.

Upon patient record review, 2 of 5 (Patient #2, 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. Patient #2 The patient medication profile lists Acetaminophen 325mg, however, the correct dosing is for Acetaminophen 500mg. Patient #3 The medication profile listed timoptic ocumeter medication to be inhaled twice daily, however, the route of medication administration is incorrect. This is to be instilled into the eyes.

Upon patient record review, 2 of 5 (Patient #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 medications and treatments. Patient #2 The medication dose listed in the POC for Acetaminophen is 325mg 2 pills ever 6hr PRN, but the correct medication dosing is 500 mg 1 pill three times a day. Patient #3 The route of medication administration listed in the POC for timoptic ocumeter eye drops is listed to be inhaled twice a day. This is an incorrect route of administration.