Every finding on record at Sunset Haven Hospice Care, LLC

Upon patient record review, 2 of 19 (Patient #10, 11) 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 #10: Patient admitted 9/25/25. Oxygen prescribed and problem identified, however, interventions do not include related safety precautions. In addition, noted cardiovascular and environmental safety problems do not include Oxygen safety precautions. Patient #11: Patient admitted 8/14/25 with forearm wound and Optifoam dressing intact from facility discharge. There were no related problems, goals, interventions initiated.

Upon patient record review, 3 of 19 (Patient #1, 3, 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 medications and treatments. Patient #1: 10/28/25 order, Cleanse wound with NS and apply Calmoseptine, no evidence of frequency. Patient #3: 9/15/25 order, RN to perform wound care as follows: Cleanse wound with normal saline or wipe then apply Calmoseptine cover with Optifoam until wound is healed. Another 9/15/25 (same date) order says RN reported that the patient's wound appears improved compared to the last report. SN visits decrease from 2x/wk to 1x/wk effective 9/14/25 to promote comfort. There was no prior order related to wound care. Patient #11: Patient admitted 9/27/25 with foley catheter in place. The only related order is 9/27/25 foley catheter care; educate caregivers on foley catheter care such as cleaning around the foley catheter and draining the bag. Problems, goals, interventions state assess urinary status every visit. Educate CG on how to properly clean outside the foley catheter and drain the catheter bag/drainage bag. RN will change drainage bag per protocol however, upon interview and request, there is no agency protocol for changing bag. Change foley catheter as needed, without qualifying circumstances of as needed change. Change incontinence pads/adult diapers - foley catheter size 16 fr, without specifying balloon size. Additionally, 11/3/25 order: Patient developed wound on left forearm. Cleanse wound with NS cover with Optifoam, order did not include frequency of treatment.

Upon patient record review, 1 of 19 (Patient #1) 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:Initial RN assessment notes that patient uses walker for ambulation. 8/16/25 note by SC that patient uses walker when he leaves home, but does not at home. Walker is not included in DME, POC or problems, goals interventions.

Upon patient record review, 3 of 19 (Patient #1, 3, 11) 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 #1: Patient admitted 8/14/25. 10/28/25 SN note: Patient "bumped into something. RN documented wound care to knee and lower leg cleansed/applied Calmoseptine with no update to problems, goals, interventions. Patient #3: Patient admitted 9/8/25. 9/15/25 order states patient developed skin tear to right buttocks with wound treatment ordered. There is no update to problems, goals, interventions. Patient #11: Patient admitted 9/27/25. 10/13/25 SN Note: Wound care provided on left forearm. 10/27/25 SN note: Wound care on the forearm was provided. No update to problems, goals, interventions

Upon client record review, 1 of 19 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: Patient admitted 9/27/25. 10/27/25 SN note: Wound care on the forearm was provided. 10/13/25 Wound care provided on left forearm however, there were no orders for wound care at the time of visits. Order was written 11/3/25, but no earlier effective date noted as part of order.

Upon personnel record review, 2 of 14 (Personnel #13, 14) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #13, 14: Upon observation, interview and personnel record review, there is evidence of contracted MSW, SC/BC which supplement direct employee staff. There is no evidence that the employment is temporary or for urgent or unusual circumstances.

Upon patient record review, 4 of 19 (Patient #2, 4, 7, 10) 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 Patients #2, 4, 7, 10: Oxygen prescribed and flow rate addressed, however there is no reference to oxygen safety precautions in aide assignment/care plan.

Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel #7: Agency reports that Volunteer Coordinator is actually a volunteer and is not paid for role. During personnel record review, there were no no tax forms in personnel file. Follow up interview reaffirmed volunteer status of Volunteer Coordinator, rather than W2.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by use of contract staff for core services of medical social services and counseling as well as volunteer coordinator not being a designated hospice employee.

Upon patient client record review, 1 of 19 (Patient #5) did not have evidence that each patient record contains Advance Directives. Patient #5: Initial RN assessment notes that patient has chosen DNR and further documents patient wishes to focus solely on comfort care. However, the EMR identifies code status as Full Code. Uploaded POLST form initially marked as attempt CPR and Full treatment, but line marked thru with date and patient initials to change to DNR status. Error date corresponds with admission and signature date. However, EMR continues to identify patient code status as Full Code. (Code status updated to DNR during survey.)

Upon patient client record review, 3 of 19 (Probably just Patient #1, 11, 14) 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 #1: Incomplete documentation of wound care performed 10/28/25 RN visit: lower knee -wound cleaned and covered and Calmoseptine applied to affected area. Skin tear also right calf. Area was cleaned, covered and Calmoseptine was applied around it. 10/30 left lower knee and right calf were cleansed, Calmoseptine was applied to the affected areas and they were covered with Optifoam. There is no evidence of cleaning agent used nor what was used to cover the wound. Patient #11: Patient admitted 9/27/25. 10/13/25 SN note: Wound care provided on left forearm. 10/27/25 SN note: Wound care on the forearm was provided. No specific details of wound care performed. Patient #14: Foley changed initial RN visit 10/11/25 due to existing catheter was not draining properly. The nurse did not specify documentation of catheter removal, including balloon cc's deflated. The nurse documented catheter was replaced, but did not specify the procedure including catheter size and balloon size. The GU console addresses size of catheter as 18, but not clear if that is size of initial catheter and/or replacement catheter. No balloon size is specified in note. 11/3/25 visit when nurse received call that catheter was leaking, RN attempted to irrigate catheter but unable, catheter removed and left out for the evening to replace in am. RN did not document cc's removed deflating balloon. Foley replaced 11/4/25. No specific nursing documentation related to procedure/foley size and/or balloon.

Upon patient record review, 1 of 6 (Patient #1) 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: Patient had oxygen DME in room. O2 not on medication profile.

Upon patient record review, 1 of 6 (Patient #1, #2 and #3) 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: This patient had a FWW and wheel chair. These were not included on the Plan of Care. Patient #2: This patient had an APP mattress. This item was not included on the Plan of Care. Patient #3: This patient had a hospital bed, BST and wheel chair. These were not included on the Plan of Care.

Upon personnel record review, 1 of 11 (Personnel #1) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: Personnel#1: Had been verbally evaluated, not an observed evaluation of the following skills: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·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 ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination Corrected on site.