Every finding on record at Signature Hospice Oregon Coast, LLC

Based on patient record review, it was determined that the agency failed to complete a bereavement assessment, which is part of the initial comprehensive assessment, in the timeframe as stipulated in the requirements of this standard. --- Findings:Review of 19 patient medical records revealed that 5 patient records (#2, #4, #11, #17, and #18) lacked documentation of a bereavement assessment completed with the initial comprehensive assessment.Review of Patient medical record #2 with an election of hospice care date of 04/16/2026, revealed the bereavement assessment was not completed until 04/23/2026, which exceeds the 5 calendar days after the election of hospice care.Review of Patient medical record #4 with an election of hospice care date of 06/03/2026, revealed the bereavement assessment was not completed until 06/09/2026, which exceeds the 5 calendar days after the election of hospice care.Review of Patient medical record #11 with an election of hospice care date of 05/25/2026, revealed the bereavement assessment was not completed until 06/04/2026, which exceeds the 5 calendar days after the election of hospice care.Similar findings were identified for Patients #17 and #18.

Upon patient record review, 1 of 11 (Patient #2) 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 medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 1 of 11 (Patient #5) 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 5: The medical record contained an order for social work visits to be as needed. Corrected on site.

Upon patient record review, 1 of 11 (Patient #2) 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 medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 1 of 11 (Patient #11) 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 11: The medical record contained nursing documentation 4/9/22 identifying patient use of walker for ambulation. There was no evidence of the walker included as DME on the plan of care.

Upon patient record review, 2 of 11 (Patients #2,#4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: The aide care plan contained tasks for two bath types allowing aide discretion; shower every visit and bed bath if shower refused. Corrected on site. Patient 4: The aide care plan contained tasks for two bath types allowing aide discretion; shower every visit and bed bath if shower refused. Corrected on site.

Upon patient client record review, 1 of 11 (Patient #10) did not have evidence that each patient record contains signed election statement in accordance with 418.24 Patient 10: The medical record contained an election of benefit form identifying the patient/representative requested the notice of hospice non-covered items. There was no evidence the patient/representative received the notification.

Upon patient record review 2 of 10 (Patients #6, #8) 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 #6: The record indicated the patient admitted on 04/07/2022 and the spiritual assessment was completed on 04/14/2022. Patient #8: The record indicated the patient admitted on 07/14/2022 and the social work assessment was completed on 07/20/2022.

Upon patient record review 1 of 10 (Patient #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #10: The record did not contain evidence that spiritual care assessment was completed.

Upon patient record review, 5 of 10 (Patients #1, #2, #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 #1 The medication profile included acetaminophen 325mg-one tablet PO every 4 hours PRN for pain/fever and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose. The medication profile included oxygen 1-3L continuous without evidence of delivery route. [corrected on site] Patient #2 The medication profile included oxygen 2L PRN for SOB on 07/07/2022 without evidence of delivery route and updated on 08/07/2022 to increase oxygen 2-4L PRN for SOB without evidence of delivery route. [corrected on site] Patient #3 The medication profile included acetaminophen 650mg rectally one suppository every 4 hours PRN for fever > 99.9 degrees and acetaminophen 500mg/15mL, take 30mL every 4 hours PRN for fever >99.9 degrees without evidence of maximum allowable dose. [corrected on site] Patient #8 The medication profile included acetaminophen 325 mg- give 2 every 6 hours for pain and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose. Patient #9 The medication profile included acetaminophen 500mg, 1-2 tablet(s) PO three times a day, acetaminophen liquid 500mg/15mL may take 15-30mL three times a day if unable to swallow, and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose.

Upon patient record review, 4 of 10 (Patient #3, #4, #7, #8) 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 #3: The record indicated patient admitted on 04/18/2022 and the bereavement assessment was completed on 05/11/2022. Patient #4: The record did not contain evidence that a bereavement assessment was completed. Patient #7: The record did not contain evidence that a bereavement assessment was completed. Patient #8: The record indicated patient admitted on 07/14/2022 and the bereavement assessment was completed on 07/21/2022.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 10 (Patient #2) 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 #2: The record contained evidence of RN visit on 07/25/2022 that patient has .3 x .3cm opening under abdominal fold which was cleaned then xeroform and optifoam applied along with instructing wife on wound care however, there was not evidence of an order for wound care. The wound was also mentioned in nurse IDG note on 07/27/2022. There is no assessment of the wound details.

Upon patient record review, 5 of 10 records (Patient #2, #3, #6, #7, #9) 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 #2, 3, 6, 7: The record indicated that the spiritual care counselor conducted initial and ongoing visits and provided spiritual counseling to the patient and caregivers. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified. Patient #9: The record indicated a PT evaluation was ordered and completed with a weekly visit frequency for specific problems/interventions/goals however, there was not evidence the plan of care was updated.

Upon patient record review, 5 of 10 records (Patient #1, #2, #3, #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. Patient #1: The plan of care contained orders of acetaminophen 325mg-one tablet PO every 4 hours PRN for pain/fever and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose. The plan of care contained an order for oxygen 1-3L continuous without evidence of delivery route. [corrected on site] Patient #2: The plan of care contained an order for oxygen 2L PRN for SOB on 07/07/2022 without evidence of delivery route and an updated order 08/07/2022 to increase oxygen 2-4L PRN for SOB without evidence of delivery route. Upon joint visit with nurse there was evidence that patient has a bipap machine and is using each night however, there was no evidence of an order for the bipap unit. [corrected on site] Patient #3: The plan of care contained orders on 04/18 for acetaminophen 650mg rectally one suppository every 4 hours PRN for fever > 99.9 degrees and 05/14 acetaminophen 500mg/15mL, take 30mL every 4 hours PRN for fever >99.9 degrees without evidence of maximum allowable dose. [corrected on site] Patient #8: The plan of care contained orders of acetaminophen 325 mg- give 2 every 6 hours for pain and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose. Patient #9: The plan of care contained orders of acetaminophen 500mg, 1-2 tablet(s) PO three times a day, acetaminophen liquid 500mg/15mL may take 15-30mL three times a day if unable to swallow, and acetaminophen suppository 650mg rectally every 4 hours PRN for fever > 99.9 degrees without evidence of maximum allowable dose.

Upon patient record review, 3 of 10 records (Patients #2, #5, #7) 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 #2: The record indicated on 08/02/2022 the patient was ordered on bactrim DS 800mg/160mg take 1 tablet by mouth times 5 days however, there was not evidence that the plan of care was updated to reflect an infection or treatment. The record contained an order for one time speech therapy evaluation and visit completed with suggestions from speech therapist however, there was not evidence this was included in plan of care. In addition, the record contained evidence in RN visit on 07/25/2022 that patient has .3 x .3cm opening under abdominal fold which was cleaned and xerofoam dressing and optifoam applied as well as instructing wife on wound care, however, there was not evidence of plan of care update for problems/interventions/goals for wound. Patient #5: The record contained order on 06/29/2022 for urinalysis with culture and sensitivity if needed and cipro 25mg tablet two times a day from 7/7-7/12/2022 for UTI however, there was not evidence of updates to the plan of care during that time. Patient #7: The record contained order for Diflucan on 07/08/2022 for vaginal yeast infection however, there was not evidence of updates to the plan of care.

Upon client record review, 2 of 10 records (Patients #2, #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated spiritual care visit frequency order on 07/07/2022 was 4M1, 5M1, 4M1 however, there was only evidence of 3 visits completed for July. The RN visit on 07/25/2022 documents patient has 0.3 x 0.3cm opening under abdominal fold which was cleaned then xeroform and optifoam applied along with instructing wife on wound care however, there was not evidence of an order for wound care. Patient #3: The record contained evidence that physician completed telehealth visit on 07/11/2022 however, the plan of care did not contain evidence for telehealth.

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. Home visit #2: During visit, nurse removed gloves twice without washing hands with hand sanitizer and/or soap and water per agency policy (Corridor policies).

Upon patient record review, 6 of 6 applicable (Patient #4, #6, #7, #8, #9, #10) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #4, 6, 7, 8, 9, 10: The record did not contain evidence of bereavement plan of care post death.

Upon personnel record review, 2 of 11 applicable (Personnel #7, #12 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #7: The record did not contain evidence of volunteer coordinator or volunteer orientation. Personnel#12: The record did not contain evidence of orientation.

Upon personnel record review, 3 of 11 applicable (Personnel #9, #10, #11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #9, #10, #11: The record contained evidence that skills competency was completed by RN versus like discipline.