Every finding on record at Summerlin Hospice and Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #2) did not contain evidence that the hospice Aide POC/assignment sheet and duties indicated what tasks were to be done by the Aide, to include any other individualized/pertinent patient information: Patient #2: All Aide POC's indicated that the patient was bedbound but during surveyor-attended home visit it was noted that the patient was able to ambulate around the home at will. The Aide POC's also indicated that patient had bedrails and these were to be in upright position. Patient was observed to be using her own private bed that did not have bedrails. DON agreed and made corrections to the Aide POC while on-site.

Upon patient record review, 2 of 14 (Patients #7 & #8) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #7: The discharge summary dated 5/8/25 reflected "The patient was a discharge from hospice services per patient and/or caregiver request, transfer to another agency, or due to natural causes as applicable." Per Admin, the patient was a discharge from services, per his request, as he wanted to elect further treatment for his cancer. Admin stated that the wrong selection was made by the RN when choosing which note to document within (chose discharge with cause) causing the unclear wording regarding the type of discharge taking place. Patient #8: LVN note dated 5/1/25 stated that the patient is "COPD-oxygen dependent" at the top of the narrative note. Near the bottom of same note she stated "Patient is currently not on oxygen but she is noted to be SOB. She reports she does not want or need oxygen at this time." Oxygen was not listed on the current medication list or on DME. The discharge summary dated 5/9/25 stated "she is currently not using supplemental oxygen and expressed no desire or need for it at this time." Admin acknowledged inaccurate charting.

Upon patient record review, 1 of 5 (Patient #5) 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 #5: Plan of care listed patient was on an anticoagulant (Plavix). No evidence of bleeding precautions listed on the plan of care.