Every finding on record at Sunset Hospice Inc

Upon patient record review 3 of 14 (Patient #2,3,5) 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 2: Patient admitted 5/7/24. Initial spiritual assessment documented 1/8/25. Patient 3: Patient admitted 10/25/24. Initial spiritual assessment documented 1/8/25. Patient 5: Patient admitted 11/14/24. Initial spiritual assessment documented 2/4/25.

Upon patient record review 8 of 14 (Patient #1,2,4,6,10,11,12,13) 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. Patients 1,4,6,10,11,12,13: There is no evidence of an initial spiritual assessment documented in the medical record. Patient 2: No evidence of initial psychosocial assessment.

Upon patient record review, 2 of 14 (Patient #4,7) 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 4: Medication list with Lumigan 0.01% ophthalmic solution present. Indication:1 drop ophthalmic every night at bedtime for glaucoma. There is no evidence of application site on the medication list. Medication list with Aspercreme 10% topical lotion present. Indication: 1 crème topical 3 times a day as needed for arthritic pain. There is no evidence of application amount or site on the medication list. COS Patient 7: Medication list includes miralax 17 grams. 1 scoop oral as needed for constipation. There is no evidence of frequency or mixing instructions in the medication list. COS

Upon patient record review, 6 of 14 (Patient #1,2,4,5,6,9) 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 1: Identified need without problems, goals, interventions on the plan of care: risk for skin breakdown; confusion. Patient 2: Identified needs with no evidence of problems, goals, interventions on the plan of care: wound; risk for skin breakdown; confusion. Patient 4: Identified needs with no evidence of problems, goals, interventions on the plan of care: confusion; nutrition including decreased appetite and aspiration precautions; risk for skin breakdown. Patient 5: Identified needs with no evidence of problems, goals, interventions on the plan of care: risk for skin breakdown. Patient 6: Identified needs with no evidence of problems, goals, interventions on the plan of care: anxiety, foley, confusion, risk for skin breakdown. Patient 9: Identified needs with no evidence of problems, goals, interventions on the plan of care: foley catheter.

Upon patient record review, 2 of 14 (Patient #4,7) 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 medications and treatments. Patient 4: Plan of care with order for Lumigan 0.01% ophthalmic solution. Indication:1 drop ophthalmic every night at bedtime for glaucoma. There is no evidence of application site on the plan of care. Plan of care with order for Aspercreme 10% topical lotion. Indication: 1 crème topical 3 times a day as needed for arthritic pain. There is no evidence of application amount or site on the plan of care. COS Patient 7: Plan of care includes order for miralax 17 grams. 1 scoop oral as needed for constipation. There is no evidence of frequency or mixing instructions on the plan of care. COS

Upon patient record review, 3 of 14 (Patient #2,4,5) 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: There is no evidence of ordered frequencies for the following tasks on the aide care plan: turn/reposition, record bowel movement; change patient’s linen. COS Patient 4: There is no evidence of ordered frequencies for the following tasks on the aide care plan: record bowel movement; transfer 1 person; mechanical lift; change patient linen. COS Patient 5:There is no evidence of ordered frequencies for the following tasks on the aide care plan: record bowel movement; change patient linen. Aspiration precautions listed on aide care plan. There is no evidence of aspiration precautions on the plan of care. COS

Upon patient record review 2 of 14 (Patient #2,5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: Physician’s aide visit frequency order is 3 times weekly, beginning on 1/14/25. There are 2 documented aide visits during the week of 2/16/25. These visits occurred on 2/18 and 2/22/25. Patient 5: Physician’s aide visit frequency order is 3 times weekly. There is no evidence of aide visits made since 3/10/25.

Upon patient record review 1 of 14 (Patient #5) 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 5: There is no evidence of aide supervisory visit documented in the medical record since 2/11/25.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 9: There is no evidence of a CTI for dates 5/2/24-6/30/24.

Upon SNF/NF contract review, 3 of 3 (all SNF contracts) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon SNF/NF contract review, 3 of 3 (all SNF contracts) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon patient record review, 5 of 5 (Patient #1 ,2 ,3 ,4, 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. Upon patient record review, 5 of 5 records (Patient #1, #2, #3, #4, #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 1, 2, 3, 4, 5: The admit order includes RN initial evaluation then every 14 days thereafter for supervisory visits and may extend up to 21 days for ongoing comprehensive assessment. Recert assessment per schedule for skilled assessment and intervention. There was no evidence of a clear visit for the RN. Corrected on site for patients 1 ,2 ,3.

Upon patient record review, 2 of 5 records (Patient #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. Patient 3: An order dated 3/8/2022 includes Stage two pressure ulcer Left Heel clean with wound cleanser, pat dry with gauze sponge, apply tetracyte to the wound bed followed by Cuticerin. Then cover with gauze and wrap with kerlex. Change dressing 2x week for 14 days and as needed if soiled or dislodged. There was no evidence as to who would perform this. An order dated 3/8/2022 includes Stage two pressure ulcer Right Heel clean with wound cleanser, pat dry with gauze sponge, apply tetracyte to the wound bed followed by Cuticerin. Then cover with gauze and wrap with kerlex. Change dressing 2x week for 14 days and as needed if soiled or dislodged. There was no evidence as to who would perform this. Both items corrected on site. Patient 5: An order dated 11/24/2022 included Generalized rashes cleanse with soap and water apply Triamcinolone cream 1% on affected areas x 14 days. There was no evidence of frequency or area to be applied.

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. Patient #2: During home visit LVN did not wash hands or use sanitizer after entering home and before entering bag to remove all supplies. Hands were washed after removing all supplies and placing on a barrier.

Upon policy and procedure review, the agency did not have evidence the policy regarding personnel who are not COVID vaccinated contained all elements including a contingency plan for personnel who are not fully vaccinated.