Every finding on record at Regal Hospice Health Inc

Upon patient record review, 1 of 16 (Patient #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 Patient #10, Plan of care documents patient has oxygen concentrator and E tanks as DME equipment. No evidence of oxygen order under the medication profile.

Upon patient record review, 2 of 16 (Patient #6,13) 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 #6, Bereavement assessment completed by SC, caregiver was documented as the bereaved person. MSW documented speaking with the daughter. The daughter was never assessed as the bereaved person. No evidence SC assessed for the bereaved family member. Patient #13, Bereavement assessment completed by SC and documented caregiver as the bereaved family member. MSW documents patient lives with adult daughter and grandson is the IHSS provider. No evidence a complete bereavement assessment was completed.

Upon patient record review, 2 of 16 (Patient #1, #6) 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 #1, RN visit notes on 7/28, 8/11, 8/25/25 completed only the supervisory visit and narrative note. No evidence of RN assessment was completed during these visits. Patient #6, RN visit note on 7/17/25 only documented supervisory visit and wrote a narrative. No evidence of RN assessment completed during this visit. Previous RN visit 2 week prior and post RN visit 2 weeks after.

Upon patient record review, 1 of 16 (Patient #1) 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, No evidence of goals and interventions to manage foley catheter noted on care plan.

Upon client record review, 1 of 16 (Patient #1) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, IDG note dated 9/16/25 had no evidence of RN comprehensive assessment, no evidence of SC assessment and MSW assessment documented "please refer to MSW note for visit details". No evidence documented of discussion of this patient.

Upon patient record review, 1 of 16 (Patient #1) 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 developed an UTI on 10/1/25 with new medication of Bactrim started, no evidence care plan was updated with goals and interventions.

Upon client record review, 14 of 16 (Patient #2,3,4,6,7,8,9,10,11,12,13,14,15,16) did not have evidence that the discharge summary includes all required information. Patient #2,3,4,6,7,8,9,10,11,12,13,14,15,16, No evidence the discharge summary documented patients symptoms, current plan of care.

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, LVN repeatedly went in and out of her nursing bag without washing hands prior to each time she entered nursing bag. Patient #2, LVN repeatedly went in and out of her nursing bag without washing hands prior to each time she entered nursing bag. Patient #3, LVN repeatedly went in and out of her nursing bag without washing hands prior to each time she entered nursing bag.

Upon patient client record review, 2 of 11 (Patient #9,10) 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 #9, IDG note from 1/11/22, missing RN signature. All other signatures present. Patient #10, MSW assessment missing signature on 12/23/21 note.