Every finding on record at Sincere Hospice and Palliative Care, Inc.

Upon patient record review, 6 of 14 (Patient #1,2,4,5,6,7) 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 1,2,4,5,6,7 did not have evidence of an Initial Bereavement Risk Assessment completed at time of survey.

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

Upon patient record review, 6 of 14 (Patient #1,2,4,5,7,9) 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 #1 resides in daughter's home. Communication Note dated 6/6/25 @ 1030am, signed by Administrator, who is not a licensed clinician: "Received call from patient's daughter that patient had episodes of vomiting clear emesis this morning. She also said patient had been more vocal about being depressed on her condition. Called MD, made aware and obtained orders to increase Paroxetine to 20mg daily and for Ondansetron 4mg every 6 hours as needed for N/V. Noted and carried out. Daughter made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified or in the IDT notes. Patient #2 resides in a private board and care home. Communication Note dated 5/24/25 @ 0126am (On Call Note) signed by Administrator, whom is not a licensed nurse: "Received call from patient's daughter requesting for a sleeping medication due to patient's current lack of sleep at nighttime. Called MD, made aware and obtained order for Temazepam 15mg 1 cap orally daily at bedtime for insomnia. Noted and carried out. Family and Facility caregiver made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, nor any mention of this in a follow up visit or in the IDT notes. A "new" order dated 6/02/25 @ 1210 am was transcribed as "Phone order/Read back and verified by" the administrator for Norco 10mg-325mg one tab orally every 12 hours for pain management. No evidence of a nurse assessing patient. Patient #4 resides in a private board and care home. Communication Note dated 6/17/25 @0624pm (on call note) signed by Administrator, who is not a licensed nurse: "Received call and photo from caregiver, Kite, that patient had an abscess on left side of face. Relayed to MD and received order for Doxycycline 100mg 1 tab orally 2x daily for 7 days for abscess. Noted and carried out. Facility caregiver made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". This order was not signed by MD as of survey. No evidence of a nurse assessing this patient for the "abscess" prior to MD being notified, or in the IDT notes. Patient #5 resides in a private board and care home. Communication Note dated 4/04/25 @ 0910am, signed by Administrator, who is not a licensed nurse: "Received call from caregiver, that patient had foul smelling urine with discharge and was lethargic. Called MD, made aware and obtained order for Levaquin 500mg 1 tab orally daily for 7 days for UTI. Noted and carried out. Facility caregiver made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, or in the IDT notes. Patient #7 resides at home with a private caregiver. Communication Note dated 3/24/25 @0718am, signed by Administrator, who is not a licensed nurse: "Received call from caregiver that patient has been coughing this morning with clear mucous. Patient requested an old medication that he took before, Benzonatate. Called MD, made aware and obtained order for Benzonatate 100mg 1 cap orally 3x daily for 5 days for cough. Noted and carried out. Patient and caregiver made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, or in the IDT notes. Communication Note dated 3/27/25 @ 1226pm, signed by Administrator, whom is not a licensed nurse: "Received call from PCG that patient had a slight temperature of 99.5 and complained of burning sensation when urinating. Called MD, made aware. Medication to be delivered STAT by pharmacy." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, or in the IDT notes. Patient #9 Resides in private board and care home. Communication Note dated 12/19/24 @ 1030 am, signed by Administrator, whom is not a licensed nurse: "Received call from med tech, Alejandro that patient has occasional cough. MD made aware and obtained order for Tussin DM syrup, give 20ml oral, every 6 hours as needed for cough. Order noted and carried out. Facility caregiver made aware." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, or in the IDT notes.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,6,7) 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 #1,2,3,4,5,6,7 Plan of care did not include DME and supplies listed. There were orders for the items, however; they were not listed on the Plan of Care.

Upon patient record review, 2 of 14 (Patient #2,8) 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. Patients #2,8 had documentation of orders for "Wound Masters" services and uploaded visit notes from the Wound Specialists. However, there was no other documentation of coordination of care. The treatments being provided by the "Wound Masters" were not part of the plan of care.

Upon patient record review, 2 of 14 (Patient #2,8) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patients #2,8 had documentation of orders for "Wound Masters" services and uploaded visit notes from the Wound Specialists. However, there was no other documentation of coordination of care. There was no evidence of discussion amongst IDT and/or Medical director for "relatedness" to terminal diagnosis.

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. The agency Administrator who is a non-licensed personnel is triaging patient calls for changes in condition and then relaying information to their physician and taking verbal orders then relaying this information to patient/family/caregivers.

Upon observation, there was no evidence the hospice provides nursing care and services by or under the supervision of a Registered Nurse. Clinical record review revealed documentation of the administrator triaging phone calls and contacting MD, and documenting orders with no involvement of an RN.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5 competency did not include all 4 bathing procedures. The competency stated, "Bed Bath" and Bath in "tub/shower". Competency only stated "Shampoo". It did not specify, "sink, tub and bed".

Condition of Participation: Clinical Records.

Upon patient client record review, 8 of 14 (Patient #1,2,3,4,5,6,7,9) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. The following did not have evidence of any documentation of the effectiveness of the medications ordered: Patient #1 resides in daughter's home. Communication Note dated 6/6/25 @ 1030am, signed by Administrator, who is not a licensed nurse: "Received call from patient's daughter that patient had episodes of vomiting clear emesis this morning. She also said patient had been more vocal about being depressed on her condition. Called MD, made aware and obtained orders to increase Paroxetine to 20mg daily and for Ondansetron 4mg every 6 hours as needed for N/V. Noted and carried out. Daughter made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. Patient #2 resides in a private board and care home. Communication Note dated 5/24/25 @ 0126am (On Call Note) signed by Administrator, who is not a licensed clinician: "Received call from patient's daughter requesting for a sleeping medication due to patient's current lack of sleep at nighttime. Called MD, made aware and obtained order for Temazepam 15mg 1 cap orally daily at bedtime for insomnia. Noted and carried out. Family and Facility caregiver made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. Order entered 06/02/25 @ 0210am. Marked as a "New" order, Norco 10mg/325mg tablet, 1 tablet, oral, every 12 hours for pain management. No documentation of response to treatment. Patient #3 resides in private board and care home. Communication note dated 04/26/25 @ 1206 pm: "MD visited patient and ordered the following: 1) D/C Current Haloperidol order, 2) Start Haloperidol 2mg tablet, give 2 tabs =4mg orally at bedtime for agitation/restlessness, and 3) D/C alendronate. Noted and carried out. Patient's son and facility made aware." No evidence of a nurse assessing the effectiveness / outcomes of these medication changes. No mention in IDT notes. Patient #4 resides in a private board and care home. Communication Note dated 6/17/25 @0624pm (on call note) signed by Administrator, who is not a licensed nurse: "Received call and photo from caregiver, Kite, that patient had an abscess on left side of face. Relayed to MD and received order for Doxycycline 100mg 1 tab orally 2x daily for 7 days for abscess. Noted and carried out. Facility caregiver made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. New Order transcribed as "Read back and verified by" the administrator dated, 7/11/25 @ 1252 pm for Norco 5-325mg one tablet oral, every 6 hours, as need for breakthrough pain. No documentation of a nurse assessment or any documentation of the effectiveness of medication. Patient #5 resides in a private board and care home. Communication Note dated 4/04/25 @ 0910am,"Received call from caregiver, that patient had foul smelling urine with discharge and was lethargic. Called MD, made aware and obtained order for Levaquin 500mg 1 tab orally daily for 7 days for UTI. Noted and carried out. Facility caregiver made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. Patient #6 Communication / On Call Note dated 5/10/25 @ 1219 pm , "Received order for MD to d/c Captopril and Metoprolol due to non-use. Caregiver and family made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. Patient #7 resides at home with a private caregiver. Communication Note dated 3/24/25 @0718am, signed by Administrator, whom is not a licensed nurse: "Received call from caregiver that patient has been coughing this morning with clear mucous. Patient requested an old medication that he took before, Benzonatate. Called MD, made aware and obtained order for Benzonatate 100mg 1 cap orally 3x daily for 5 days for cough. Noted and carried out. Patient and caregiver made aware." No evidence of any mention of this in a follow up visit or in the IDT notes. Communication Note dated 3/27/25 @ 1226pm, "Received call from PCG that patient had a slight temperature of 99.5 and complained of burning sensation when urinating. Called MD, made aware. Medication to be delivered STAT by pharmacy." No evidence of any mention of this in a follow up visit or in the IDT notes. Patient #9 Resides in private board and care home. Communication Note dated 12/19/24 @ 1030 am, signed by Administrator, whom is not a licensed nurse: "Received call from med tech, Alejandro that patient has occasional cough. MD made aware and obtained order for Tussin DM syrup, give 20ml oral, every 6 hours as needed for cough. Order noted and carried out. Facility caregiver made aware." No evidence of any mention of this in a follow up visit or in the IDT notes.

Upon patient client record review, 3 of 14 (Patient #1,3,4) did not evidence that each patient record contains SIGNED physician orders. Patient #1 ALL Admission orders for SOC 5/26/25 were not signed by the physician as of survey review 7/16/25. Patient #3 resides in private board and care home. Communication note dated 04/26/25 @ 1206 pm: "MD visited patient and ordered the following: 1) D/C Current Haloperidol order, 2) Start Haloperidol 2mg tablet, give 2 tabs =4mg orally at bedtime for agitation/restlessness, and 3) D/C alendronate. Noted and carried out. Patient's son and facility made aware." The medication orders were entered by the administrator and electronically signed stating she "Read back and verified order". This order was not signed by physician as of survey. Patient #4 resides in a private board and care home. Communication Note dated 6/17/25 @0624pm (on call note) signed by Administrator, whom is not a licensed nurse: "Received call and photo from caregiver, Kite, that patient had an abscess on left side of face. Relayed to MD and received order for Doxycycline 100mg 1 tab orally 2x daily for 7 days for abscess. Noted and carried out. Facility caregiver made aware." Also on 6/02/25, Administrator documented a phone order from the medical director for Macrobid 50mg, 1 tablet orally daily for 30 days, UTI prophylaxis. The medication orders were entered by the administrator and electronically signed stating she "Read back and verified order". These orders were not signed by MD as of survey. Communication Note dated 3/27/25 @ 1226pm, signed by Administrator, whom is not a licensed nurse: "Received call from PCG that patient had a slight temperature of 99.5 and complained of burning sensation when urinating. Called MD, made aware and obtained order for Levaquin 500mg, one tab daily x 10 days. Noted and carried out. PCG made aware. Medication to be delivered STAT by pharmacy." The medication order was entered by the administrator and electronically signed stating she "Read back and verified order". No evidence of a nurse assessing this patient prior to MD being notified, nor any mention of this in a follow up visit or in the IDT notes. This order was not signed by physician as of survey.

Upon patient client record review, 6 of 14 (Patient #1,2,3,4,5,6) 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. Numerous visit notes submitted by RN's and LVN's were not signed by the actual Skilled Nurse making the visit. They were electronically signed by the DPCS or the Administrator. Agency Administrator and DPCS explained that they "QA" the notes and then sign and submit. Education provided regarding the notes must be signed by the employee that actually makes the visit. Patient #1 RN visits dated 6/9/25 and 6/23/25 signed by Administrator 0n 7/16/25. LVN visits dated 5/28, 6/25, 7/3, 7/10 signed by Administrator on 7/16/25. LVN visits dated 6/4, 6/13, 6/18 signed by DPCS 6/25. Patient #2 RN visits dated 7/6, 6/29 signed by Administrator 7/16. RN visit dated 6/01 signed by DPCS 6/25. LVN visits dated, 7/12, 6/30, 6/25, 6,20 signed by Administrator 7/16. LVN visits dated 6/13 signed by DPCS 6/25. LVN visits dated 6/9, 6/4, 5/27, 5/21 signed by DPCS on 6/16. Patient #3 RN visits dated 7/13, 6/29, 6/1 signed by Administrator 7/16. LVN visits dated 7/17, 6/30, 6/25, 6/20 signed by Administrator 7/16. Patient #4 LVN visit dated 5/31 signed by Administrator on 6/11. Patient #5 RN Recert assessment dated 6/9 signed by administrator on 7/16. Patient #6 RN Recert assessment dated 6/21 signed by Administrator on 7/14. SCP visit note dated 11/8/24 signed by Administrator on 7/15/25.

Upon client record review, 1 of 14 (Patient #10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #10 Transferred to another Hospice. No evidence of any records sent to receiving Hospice.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11 Revoked hospice, no evidence of a summary sent to a physician.

Condition of Participation: Drugs and Biologicals, Medical Supplies, and Durable Medical Equipment.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. All patients had various "physician orders" documented by the Administrator whom is not a licensed clinician that may take an order from a physician. The following were transcribed by the administrator and electronically signed in the signature space stating, "Phone order /Read back by". Patients #2,3,4,5,6,11,12 All Admission orders for start of care were documented/transcribed and signed as "phone order / Read back by" administrator. Patient #1 on 6/4/25 for Tramadol and Gabapentin, 6/6/25 Paroxetine and Ondansetron. Patient #2 on 5/24/25 Temazepam. 6/2/25 Norco Patient #3 on 4/26/25 Haldol Patient #4 on 6/2/25 Macrobid, 6/17/25 Doxycycline, and 7/11/25 Norco Patient #5 on 4/4/25 Levaquin, 6/2/25 Macrobid Patient #6 on 4/18/25 D/C Vitamin A, D3, and Docusate, 5/10/25 D/C Captopril and Metoprolol Patient #7 on 6/29/24 Docusate, Tamsulosin, Omeprazole, 11/06/24 Lab orders, and 3/07/25 Levaquin Patient #8 on 4/21/25 Sertraline Patient #9 on 12/19/24 Tussin DM Patient # 10 on 10/09/24 Furosemide Patient #11 on 8/15/24 Wound care orders Patient #12 on 4/27/25 Preparation-H, 5/14/25 D/C Amlodipine and Losartan Patient #13 on 7/26/24 In /out Cath for U/A and C&S Patient #14 on 7/12/24 Cipro and Bactrim, and 7/21/24 Lorazepam and Morphine.

Upon personnel record review, 3 of 13 (Personnel #11,12,13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. This was corrected during survey. The contracted company provided the needed documentation while surveyor on site. However; there was documentation of the Physical Therapist (personnel #11) doing an evaluation on patient #8 on 1/22/25, prior to agency having criminal background or sex offender check on file.

Upon patient record review, 2 of 5 (Patient #3,#4) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 3,4: Did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) 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. Patients 1,2,3,5: The medication profile contains Acetaminophen 325mg 1 tab every 4 hours, NTE 3gm/24 hours. NTE is not an approved abbreviation. Corrected on site.

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) 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 1,2,3,5: The POC contains Acetaminophen 325mg 1 tab every 4 hours, NTE 3gm/24 hours. NTE is not an approved abbreviation. Corrected on site.

Upon patient client record review, 1 of 5 (Patient #4) 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 4: The clinical record contains a CTI narrative by the physician stating "Admit to hospice, 80 year old female for first certification period 10-03-21 to 1-20-22." The patient's SOC was 10-23-21.

Upon personnel record review, 2 of 11 (Personnel #7 and #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 7: The OT did not have evidence of a criminal background check on file. The agency did have the OT's background checked while surveyor was onsite. Personnel 8: The ST did not have evidence of a criminal background check on file. They agency did have the ST's background checked while surveyor was onsite.