Every finding on record at Santa Isabel Hospice, Inc.

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 8/27/25 LVN visit reports anxiety and teaching of non-pharmacological techniques and states "If anxiety becomes persistent or unmanageable to contact hospice", 9/3/25 LVN states "patient having periods of anxiety", no evidence of either visit that the patient condition was reported to the RN and no evidence of follow up by RN to add interventions.

Upon patient record review, 3 of 14 (Patient #4,6,8) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #4 8/25/25 RN states "patient observed to appear anxious, with behaviors including restlessness, fidgeting and rapid speech", patient reports feeling on edge and unable to relax for over a week. RN encouraged patient to explore coping strategies. No evidence that physician was notified with a change in patient status. 8/27/25 LVN visit reports anxiety and teaching of non-pharmacological techniques and states "If anxiety becomes persistent or unmanageable to contact hospice", 9/3/25 LVN states "patient having periods of anxiety", no evidence of either visit that the patient condition was reported to the RN and no evidence of follow up by RN to add interventions. Patient #6-9/14/25 SN visit states "Caregiver reports patient continues to have episodes of feeling sad, low energy, difficulty sleeping and refusing to eat", RN noted "patient continues to take Escitalopram 10mg as prescribed", no evidence of reporting the condition to the physician or interventions taken place. 9/5/25 MSW visit states "upon visit, patient was in a depressive mode and unable to communicate clearly" and documented Anxiety/Psychosocial scale as "moderate", no evidence the RN was notified of patient condition or that MSW offered any available interventions. Patient #8-8/17/25, 8/31/25 and 9/14/25 SN reports patient with anxiety and Lorazepam 0.5mg BID taken as prescribed, no evidence that the physician was contacted with change in patient status.

Upon patient client record review, 1 of 14 (Patient #12) did not evidence that each patient record contains physician orders. Patient #12-6/21/25, Continuous care initiated, no evidence of orders in place to change the level of care.

Upon patient client record review, 1 of 14 (Patient #9) 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 #9-9/14/25, RN completed an aide supervisory visit, no evidence of aide being provided to the patient.

Upon patient record review, 1 of 5 (Patient #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 3: Upon home visit finding, there were several medications found in the home in the patients pill box that were not on the POC. Patient reports taking these meds: Tylenol 500mg, amlodipine besylate 5mg daily, Ibuprofen 600mg 1 TID prn, clonidine HCL 0.1mg BID, Dexilant DR 30mg 1 daily, Hydrochlorothiazide 200mg daily, hydroxyzine HCL 25mg 1 TID, Benicar HCT 20-12.5 1 daily, Vitamin D 50,000 Units 1 tab every 2 weeks.