Every finding on record at Puricare Health Services LLC

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 Patients #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: Patient admitted for ASHD on 7/11/25. He stated his self identified threshold for pain was a level 2. On several dates listed, patient's pain rating was higher than 2 and the nurse advised patient to take medications as ordered, there was no evidence of physician update or follow up call or visit to patient for several days. On 07/16/25, patient complained of pain of level 8. No visit for 6 days. On 07/22/25, patient complained of pain of level 8. No visit for 8 days. On 07/30/25, patient complained of pain of level 10. No visit for 9 days. On 08/14/25, patient complained of pain of level 9. No visit for 7 days. On 09/04/25, patient complained of pain of level 10. No visit for 7 days. On 09/17/25, patient complained of level 10 pain and an order was obtained for patient to start MS Contin. There was no follow up visit or call documented for new medication for 7 days.

Upon patient record review, 1 of 14 (Patient #6) 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 #6: Patient is on service for Chronic Systolic Heart Failure and is a full code. The MSW has not included assessing code status and mortuary arrangements in the plan of care.

Upon patient record review, 2 of 14 (Patient #1, 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 #1: Wound order for "unstageable wounds on bilateral buttocks. Instructed to cleanse affected area with clean water and mild soap, pat dry. Apply Calmoseptine daily and prn." In the same visit, the order does not specify a reason for PRN dressing changes and does not specify when the hospice RN will change dressing as opposed to the caregiver. Patient #4: Wound narrative on nursing visit on 11/03/25 reads, "clean wound with wound cleanser, cover with gauze, secure with foam dressing." The skin assessment from same visit states, "cleansed with wound cleanser, sterile gauze, Mepilex placed." It does not include location or type of wound, who will change and how frequently. It is also outside the most current order, which reads: "mid- thoracic back, non healing surgical wound cleanse with cleanser, allograft placed, packed with calcium alginate, foam dressing placed." There is no frequency, nor specification of who is to change the dressing and when, and no specification of type of wound cleanser. There is also no order regarding wound company seeing patient

Upon patient record review, 7 of 14 (Patient #1, 3, 5, 7, 8, 9, 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. Patients (1, 3, 5, 7, 8, 9, 10) were all missing gloves, wipes, and underpads. Patient #1 also missing O2 supplies, wound supplies, briefs. Patient #3 also missing O2 supplies, briefs. Patient #7 also missing wound care supplies. Patient #8 also missing briefs, wound care supplies. Patient #9 also missing briefs. Patient #10 also missing glucometer supplies, briefs, oxygen supplies.

Upon patient record review, 4 of 14 (Patient #1, 3, 4, 8) 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 #1: Patient has a plan of care for wound care. The orders have changed, including type and stage of wound, however the plan of care has not been updated since admission. Patient #3: Patient was admitted on 07/21/25. The patient was a full code. Since this time, the patient has become a DNR. The MSW plan of care is not updated to reflect that change. Patient #4: The patient has had ongoing issues with uncontrolled pain. The medications were changed on 09/17/25 initiating a long acting daily opiate. There were no updates to the plan of care for pain since admission. Patient #8: Patient admitted with "chronic ulcer to left lower leg. On 01/06/25, it is documented that patient had 4 wounds. There was no update to the plan of care with new wound information.

Upon client record review, 2 of 14 (Patient #1, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The plan of care states "SN to assess patient's blood glucose level as ordered. Range for blood sugar to be between 60-140. There is no evidence the nurse is checking glucose levels at visits. There is no documentation of blood glucose levels obtained by caregiver. The patient plan of care states "assess skin integrity every visit, assessing size, integrity, location of wounds. The wounds are not being fully assessed and no measurements have been obtained. Patient #10: The plan of care states "SN to assess patient's blood glucose level as ordered. Range for blood sugar to be between 60-140. There is no evidence the nurse is checking glucose levels at visits. There is no documentation of blood glucose levels obtained by caregiver.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patients #1 and #4 were ordered to receive wound therapy from an outside wound company for wound care that was not specified as unrelated to the patients hospice diagnosis. The agency is still having the RNs change the dressings. Although, RN's were completing dressing changes there was no evidence by hospice agency of assessments on patients, as the wound care contract states wound care company would do all assessments and measuring. The agency wound care policy indicates the RN is to "conduct an initial and ongoing wound assessment including location, size, drainage, odor, pain, and surrounding tissue condition.""document wound assessment, dressing type, drainage, pain score, and patient tolerance each visit. Eventually, for one of the two patients, the wound care company was doing allograft treatments and that order was added.

Upon patient record review 1 of 14 (Patient #2) 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 #2: During the home visit with the aide, the caregiver stated that the patient had a shower that morning. The aide did incontinence care and changed patients brief. The aide did not complete any further items listed on the aide assignment including oral care (brushing teeth), brush hair, clean and file nails, apply lotion, change linens.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidence by core nursing services not being provided by employees of agency for non complex wound care needs.

Upon patient client record review, 1 of 14 (Patient #4) 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 #4: This patient record does not show evidence that the patient/caregiver was given an election addendum. The consent that the agency uses per their policy was blank where it states whether the patient does or does not elect an election addendum. There is no evidence in record stating the wound the patient had, which subsequently received wound care from an outside company, was related or unrelated to the hospice diagnosis.

Based on interview and review of the facility's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies were based on a current geographically correct all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current 18 patients receiving care from the agency and any employed staff. Findings include: --- For Submission Purpose Only. .

Based on record review and interview, the facility failed to ensure the initial Interdisciplinary Group (IDG) completed the comprehensive assessments within five days of the Hospice admission for 1 of 14 patients (Patient (P) 1) reviewed. This failure could affect the care the patient and/or family received due to inaccurate assessment of needs.Findings include: --- For Submission Purpose Only .

Based on record review and interview, the facility failed to ensure a copy of the legal Power of Attorney document was maintained in patients' medical records for 1 of 14 sampled patients (Patient (P) 8). The facility identified P8 as having a POA; however, there was no documented evidence of P8's POA in the patient's medical record. This failure had the potential to allow anyone to verbally state an ability to make decisions for a patient without having legal authority.Findings include: --- For Submission Purpose Only. .

Based on observation, interview, policy review, and review of the Centers for Disease Control and Prevention's website, the Hospice Agency failed to ensure standard precautions were maintained during and after direct patient care for 1 of 3 patients (Patient (P) 10) observed during a home visit out of a total sample of 14. This deficient practice had the potential to adversely affect all eight patients receiving care from the hospice agency. Findings include: --- For Submission Purpose Only. .

Upon observation, there was not evidence that the Hospice's Emergency Preparedness Plan included strategies for addressing those emergency events, as identified by the Hospice's Hazard Vulnerability Risk Assessment, to be at greatest risk for the organization.

Upon patient record review, 2 of 5 (Patients #1 and 2) did not contain a current/comprehensive Medication Profile: Patient #1: The Medication Profile included, "Meloxicam 7.5 mg, i tab daily as needed", without an indication for such as needed dosing. Patients #1 and 2: Both of these clinical records reflected that these patients had/used Physician-ordered Oxygen. The Oxygen was not included on their Medication Profiles.

Upon patient record review, 3 of 5 (Patients #1, 4, and 5) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, specifically complete medication and treatment orders: Patient #1: The POC included, "Meloxicam 7.5 mg, i tab daily as needed",without an indication for such as needed dosing. Patients #4 and 5: The Initial RN Assessments, reflected that both of these patients were using a Physician-ordered T.E.N.S. Unit/treatment. This treatment was not included on these patients' current Plan(s) of Care, to include any associated details of its use/administration.

Upon patient record review, 2 of 5 (Patients #1 and 2) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, specifically DME and Supply needs: Patient #1: The POC dated 07/19-10/16/22 listed the patient as having the following DME: Commode and Wheel Chair. During Surveyor-attended home visit on 09/13/22 the patient reported not having this DME. The same POC indicated that the patient did not have the following DME: Walker and bed. During Surveyor-attended home visit on 09/13/22 the patient reported that she did have this DME. Patient #2: The POC dated 07/31-10/28/22 listed the patient as having the following DME: Commode, Cane, and Hospital Bed. During Surveyor-attended home visit on 09/13/22 the patient reported not having any of this DME.

Upon patient record review, 3 of 5 (Patients #1, 4, and 5), receiving Aide services, did not contain evidence that the RN-established Hospice Aide POC/assignments and duties reflect: The RN-established Aide Plan of Care must clearly delineate which tasks are to be done by the Aide, and the frequency of such tasks: Patient #1: The current Aide Plan of Care assigned, "Tub Bath" every Aide visit. During the Surveyor-attended home visit on 09/13/22, the patient reported that the Aide assists her to shower, while sitting on a chair in the shower. The RN confirmed that the Aide assignment should have assigned a shower. Patient #4: The completed Nevada State POLST reflected that this patient was a Full Code. The Aide POC incorrectly identified the patient as a D.N.R. Patient #5: The current Aide POC assigned the Aide to provide both a Shower and Complete Bed Bath.

Upon patient record review, 5 of 5 (Patients #1, 2, 3, 4, and 5) did not contain a patient-signed Election of Hospice Benefit Statement, in accordance with 418.24. These patient-signed Election Statements did not include the following required content: As a Medicare Hospice beneficiary, you have the right to contact the Beneficiary and Family-Centered Care Quality Organization (BFCC-QIO), to request immediate advocacy if you disagree with any of the Hospice's determinations. The BFCC-QIO that services your area is: BFCC-QIO Name: BFCC-QIO Phone Number: The Hospice had not filled in the above blank spaces, with the details of the patients' QIO office, and associated phone number.

Upon patient record review, 1 of 2 applicable (Patient #5), live discharges, did not contain a Discharge Summary which included all CMS-required content. The 07/09/22 DC Summary did not contain the following required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders