Every finding on record at Summer Breeze Healthcare

Upon patient record review, 3 of 14 (Patients #1, 2, 10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1, 2, 10: The patient/caregiver signed consents upon admission stating they chose the hospice medical director. The doctors name was printed onto the signed consents. He left the agency in April 2025, and the new medical director was contracted. This new medical director became the attending, however, there was no evidence of documentation of discussion with the family, and no evidence of a change in physician consent or form completed with patient or family.

Upon patient record review, 10 of 14(Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 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 Patients #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting. In addition, these patients were provided with oxygen. Oxygen is not on the medication profile.

Upon patient record review, 1 of 14 (Patient #1) 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: The patient medication order reads, "Volsartan 80mg. One tablet every morning at 8am. Hold medication if systolic BP is less than 120." During RN visits on 07/07/25, 07/14/25, 07/23/25/ 08/04/25, 08/11/25, and 09/03/25, systolic blood pressure readings were below 120. There was no evidence that the RN notified the physician for further orders or changes to the plan of care"

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #1: The patient medication order reads, "Volsartan 80mg. One tablet every morning at 8am. Hold medication if systolic BP is less than 120." During RN visits on 07/07/25, 07/14/25, 07/23/25/ 08/04/25, 08/11/25, and 09/03/25, systolic blood pressure readings were below 120. There was no evidence of the nurse educating the family to hold the medication.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1,3,6: The patient sees the hospice spiritual care. There is no evidence of interventions or goals for spiritual care on the plan of care. The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #2,4,7,8,9,10: The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #5: The patient was provided with a suction machine, however, there is no evidence of interventions or goals for suction machine. There was no evidence of interventions or goals related to the comfort kit in the plan of care. The patient has history of epileptic seizures and is prescribed Depakote. There is no evidence of interventions or goals for seizures.

Upon patient record review, 2 of 14 (Patients #4, 6) 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 #4 and 6: The patient has spiritual care. The order, however, reads initial visit then prn. PRN visits cannot stand alone.

Upon patient record review 2 of 14 (Patients #3, 6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #3: In the record, the hospice aide began seeing patient on 07/30/25. The RN did a supervised visit on 08/08/25. The hospice aide continues to see patient, however, there is no evidence of an RN supervised visit since 08/08/25, which was 25 days ago. Patient #6: In the record, the hospice aide began seeing the patient on 07/30/25. A supervised visit was completed by the RN on 08/12/25 and 08/18/25. There is no evidence of further RN supervision which is now 17 days.

Observed in Record Review. In 3 of 5 patient records reviewed, During review of HV# 1, RR# 1, and RR# 2's patient records review, it was noted the organization had not ensured the initial bereavement assessment was completed as required by policy. For example: review of HV# 1's patient record revealed no documentation of an initial bereavement assessment. Review of RR# 1 and RR# 2's patient records revealed the initial bereavement assessment was not completed by the social worker, as required by policy. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 2 of 3 home visits conducted, During HV# 1 and HV# 3's home observation it was noted the patient records were inaccurate. For example: during HV# 1’s home observation HV# 1 shared there was no oxygen in the home and there never had been oxygen. Review of HV# 1’s patient record revealed the RN start of care comprehensive assessment with documentation HV# 1 was receiving oxygen at 2-3L as needed. Further review of HV# 1’s patient record revealed an oxygen safety risk assessment with documentation the equipment was stored safely, and the concentrator was plugged into the wall. During HV# 3’s home observation it was noted HV# 3 had no oxygen. Review of HV# 3’s patent record revealed the RN start of Care comprehensive assessment and recertification comprehensive assessment with documentation HV# 3 was receiving oxygen at 2-3L as needed. Further review of HV# 3’s patient record revealed a start of care and recertification oxygen safety risk assessment with documentation the equipment was stored safely, and the concentrator was plugged into the wall. This was observed by the Administrator, reviewed, discussed, and validated by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 4 of 5 patient records reviewed, During HV#1, HV# 3, RR# 1, and RR# 2's patient records review, it was noted the organization had not ensured the plans of care had individualized measurable goals. For example: review of HV# 3’s patient record revealed the plan of care with the Gastrointestinal goal “Optimal bowel elimination and comfort”. Further review of HV# 3’s plan of care revealed the Musculoskeletal goal “patient/PCG will demonstrate/express increase strength/energy for optimal functioning”. However, there was no documentation of what an optimal bowel elimination would be or optimal functioning for HV# 3. Review of HV# 1’s patient record revealed the plan of care with the Musculoskeletal goal “Patient will maintain or will indicated improvement on level of functional ability”. However, there was no documentation of what an improvement of functional ability would be for HV# 1. Review of RR# 1’s patient record revealed the plan of care with the Psychosocial goal “Patient and family to be learned on progression of illness, dying process, and grieving throughout the certification period”. However, there was no documentation of what learned on progression would be for RR# 1. Review of RR# 2's patient record revealed the plan of care with the Pain goal, that patient would have adequate pain relief within 1-2 hours of interventions. However, there was no documentation of what adequate pain relief was for RR# 2. This was reviewed, discussed, and validated by the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV# 1, HV# 2, and HV# 3's patient records review it was noted the nurses failed to perform hand hygiene consistent with the organization's Hand Hygiene policy. For example: during HV# 1's home observation the LVN was observed applying alcohol-based hand sanitizer and then wiping her hands with a paper towel. During HV# 3's home observation the RN was observed applying alcohol-based hand sanitizer and then wiping her hands with a paper towel. During HV# 2's home observation the RN failed to perform hand hygiene after removing his gloves. This was observed by the Administrator, discussed with the Administrator and Director of Patient Care Services and validated. Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 2's home observation it was noted the LVN had not followed the organization's Bag Technique policy. For example: during the home observation the LVN was observed entering the bag on multiple occasions without performing hand hygiene. This was observed by the Administrator, discussed with the Administrator and Director of Patient Care Services and validated.

Observed in HR File Review. In 1 of 1 Home Health Aide HR files reviewed, During the Home Health Aide HR file review it was noted the organization had not ensured the initial aide competency was evaluated by observation/demonstration. For example: review of the initial Hospice Aide Competency revealed all aide competencies were completed verbally. Review of HV# 3's patient record revealed the Home Health Aide had provided services twice weekly for approximately two months prior to the surveyor review of the record. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed with recertification, During HV# 2 and HV# 3's patient record review it was noted the organization had not ensured the Medical Director reviewed the clinical information and signed the certificate of terminal illness (CTI) prior to the recertification. For example: review of HV# 2's patient record revealed a recertification CTI signed after the recertification. Further review of the recertification CTI revealed documentation, under physician, verbatim documentation from the initial CTI and no documentation the Medical Director reviewed the Team Assessment or Medical history, Record and Patient. This was reviewed, discussed, and validated by the Administrator and Director of Patient Care Services. Review of HV# 3's patient record revealed the initial certification ended one day before the surveyor review of the record. Review of HV# 3's recertification CTI revealed no Medical Director/physician documentation or signature.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 3's patient record review it was noted the organization had not maintained the security and integrity of health information. For example: review of the home folder, during the home observation, revealed the yellow copy of the Informed Consent and Treatment Authorization form with documentation of the Election of Benefit date one day prior to the start of care date and signed by the patient representative. Review of the patient record revealed the white/original Informed Consent and Treatment Authorization form with the original date crossed out and the start of care date written above. This was observed by the Administrator, reviewed, discussed, and validated by the Administrator and Director of Patient Care Services.