Every finding on record at Sierra Peak Health Inc

Upon patient record review, 3 of 14 (Patients #3,8,9) 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 #3: Hospice medication profile indicated Acetaminophen 325mg give 2 tabs PRN. The B&C medication profile indicated Acetaminophen 325mg give 1 tab PRN. Patients #8,9: These patients had Polyethylene Glycol 17 gm powder orders with no diluent included listed on their medication profiles.

Upon patient record review, 6 of 14 (Patients #5,6,7,10,13,14) 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. Patients #5,6,7,10,13,14: These patients did not have an initial Bereavement Risk Assessment in their record.

Upon patient record review, 1 of 14 (Patient #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 #3: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicates patient has metformin 500 mg BID. There was no evidence of problems, goals, or interventions related to the Endocrine system.

Upon patient record review, 13 of 14 (Patients #1,2,3,4,6,7,8,9,10,11,12,13,14) did not have evidence the plan of care (POC) 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 Patients #1,2,3,4,6,7,8,9,10,11,12,13,14: The POC Volunteer visit frequency, indicated "Volunteer per patient request." These frequencies did not include a baseline visit frequency.

Upon patient record review, 2 of 14 (Patients #8,9) 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. Patients #8,9: Polyethylene Glycol 17 gm powder order with no diluent included listed on the plan of care.

Upon patient record review, 2 of 14 (Patient #5,6) 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 #5: The record reflected that this patient had an over-bed table and shower chair. These were not included on the Plan of Care. Patient #6: The record reflected that this patient had a nebulizer machine for Albuterol Sulfate solution 3mL Q6 hours This was not included on the Plan of Care.

Upon patient record review 9 of 14 (Patients #1,2,4,5,6,7,8,9,10) 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 (POC) • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The POC listed Aide visit frequency of, 5 X's per week (7/30/25). For first benefit week, there was only 1 visit on 7/31/25. The Aide visit on 2/3/26 did not have the task "bathroom" checked as completed on the the plan of care/visit note. Patient #2: The POC listed Aide visit frequency of, 5 X's per week (4/29/25). For first benefit week, there was only 4 visits on 4/30, 5/1, 5/2, 5/3. Patient #4: The POC listed Aide visit frequency of, 2 X's per week (10/25/25). For first benefit week, there were no visits performed by the Aide. Patient #5: The POC listed Aide visit frequency of, 5 X's per week (8/6/25). For first benefit week, there was only 1 visit on 8/7/25. Patient #6: The POC listed Aide visit frequency of, 5 X's per week (12/26/25). For first benefit week, there were no visits performed by the Aide. Patient #7: The POC listed Aide visit frequency of, 7 X's per week (12/26/25). For first benefit week, there were no visits performed by the Aide. Patient #8: The POC listed Aide visit frequency of, 5 X's per week (12/24/25). For first benefit week, there was only 1 visit on 12/26/25. Patient #9: The POC listed Aide visit frequency of, 5 X's per week (12/13/25). For first benefit week, there were no visits performed by the Aide. Patient #10: The POC listed Aide visit frequency of, 5 X's per week (12/17/25). For first benefit week, there was only 3 visits on 12/17, 12/18, 12/19.

Upon contract review, 1 of 4 (Primo Therapy PT/OT/ST contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Furnished in a safe and effective manner

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient #3: There was no evidence that the hospice obtained CTI within 2 calendar days after hospice care is initiated, oral or written certification of the terminal illness by the hospice medical director/attending physician. The patient was admitted on 5/12/25 and the CTI was completed on 5/15/25.

Upon patient client record review, 3 of 14 (Patients #6,7,9) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #6,7,9: The Hospice Medicare Election statement did not provide BFCC-QIO contact information in space provided on form.

Upon client record review, 2 of 14 (Patients #11,12) did not have evidence that the discharge summary included all required information as follows: • The patient's current plan of care

Upon SNF/NF contract review, 1 of 4 (Torrey Pines SNF/GIP/RIP contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.