Every finding on record at Sunset Hospice, L.L.C.

Based on record review and interview, the hospice failed to ensure hospice aide frequencies were met in accordance with the plan of care for nine (Patient's #1, 2, 3, 4, 5, 6, 8, 10 and 14) of 19 patients. --- Patient #1 A plan of care dated 12/26/24 to 02/23/25 documented a hospice aide frequency of one visit per week for one week and three visits per week for eight weeks. A review of the clinical record showed the following: A hospice aide visit dated 01/01/25 was missed due to a holiday for the week of 12/29/24 to 01/04/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/10/25 was missed due to inclement weather for the week of 01/05/25 to 01/11/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #2 A plan of care dated 11/08/24 to 01/06/25 documented a hospice aide frequency of one visit per week for one week and three visits per week for eight weeks. A review of the clinical record showed the following: A hospice aide visit dated 01/02/25 was missed due to being out sick for the week of 012/29/24 to 01/04/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #3 A plan of care dated 12/24/24 to 02/21/25 documented a hospice aide frequency of four visits for one week and five visits for eight weeks. A review of the clinical record showed the following: A hospice aide visit dated 12/25/24 was missed due to a holiday for the week of 12/24/24 to 12/28/24 (three of four visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/01/25 was missed due to a holiday for the week of 12/29/24 to 01/04/25 (four of five visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/10/25 was missed due to inclement weather for the week of 01/05/25 to 01/11/25 (four of five visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #4 A plan of care dated 02/07/25 to 05/07/25 documented a hospice aide frequency of five visits per week for twelve weeks. A review of the clinical record showed the following: A hospice aide visits dated 02/19/25 was missed due to inclement weather for the week of 02/16/25 to 02/22/25 (four of five visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #5 A plan of care dated 01/02/25 to 03/02/25 documented a hospice aide frequency of two visits per week for one week and five visits per week for eight weeks. A review of the clinical record showed the following: Hospice aide visits dated 01/09/25 and 01/10/25 were missed due to inclement weather for the week of 01/05/25 to 01/11/25 (three of five visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visits. Patient #6 A plan of care dated 12/09/24 to 03/08/25 documented a hospice aide frequency of one visit per week for one week, two visits per week for three weeks, three visits per week for one week, two visits per week for one week, three visits per week for one week, two visits per week for two weeks, three visits per week for two weeks and four visits per week for two weeks. A review of the clinical record showed the following: Hospice aide visits dated 01/07/25 and 01/09/25 were completed for the week of 01/05/25 to 01/11/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Hospice aide visits dated 01/21/25 and 01/23/25 were completed for the week of 01/19/25 to 01/25/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #8 A plan of care dated 12/24/24 to 02/21/25 documented a hospice aide frequency of two visits per week for eight weeks and two visits per week for one week. A review of the clinical record showed the following: A hospice aide visit dated 01/10/25 was missed due to inclement weather for the week of 01/05/25 to 01/11/25 (four of five visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 02/13/25 was missed due to facility to resume care for the week of 02/09/25 to 02/15/25 (one of two visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #10 A plan of care dated 11/14/24 to 02/11/25 documented a hospice aide frequency of one visit per week for one week, three visits per week for twelve weeks and one visit per week for one week. A review of the clinical record showed the following: A hospice aide visit dated 11/29/24 was missed due to the aide having paid time off for the week of 11/17/24 to 11/23/24 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 12/25/24 was missed due to a holiday for the week of 12/24/24 to 12/28/24 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/01/25 was missed due to a holiday for the week of 12/29/24 to 01/04/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/10/25 was missed due to inclement weather for the week of 01/05/25 to 01/11/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. Patient #14 A plan of care dated 11/11/24 to 01/09/25 documented a hospice aide frequency of three visits per week for eight week and two visits per week for one week. A review of the clinical record showed the following: A hospice aide visit dated 12/25/24 was missed due to a holiday for the week of 12/24/24 to 12/28/24 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. A hospice aide visit dated 01/01/25 was missed due to a holiday for the week of 12/29/24 to 01/04/25 (two of three visits completed) with no documentation of patient or caregiver refusal, no change in ordered frequencies or attempts to reschedule the missed visit. On 03/06/25 at 2:30 pm, Staff C stated the ordered frequency for Patients #1, 2, 3, 4, 5, 6, 8, 10 and 14 were not met in accordance with the plan of care.

Based on record review and interview, the hospice failed to ensure a patient-specific individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for thirteen (Patients #1, 2, 3, 4, 5, 6, 8, 10, 12, 13, 14, 16 and 17) of 19 patients reviewed. --- Patient #1 A plan of care dated 12/26/24 to 02/23/25 documented a primary diagnosis of senile degeneration of the brain and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #2 A plan of care dated 11/08/24 to 01/06/25 documented a primary diagnosis of cerebral infarction and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #3 A plan of care dated 12/24/24 to 02/21/25 documented a primary diagnosis of cancer of the bladder and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 02/07/25 to 05/07/25 documented a primary diagnosis of malignant neoplasm of bronchus or lung and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #5 A plan of care dated 01/02/25 to 03/02/25 documented a primary diagnosis of heart failure and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #6 A plan of care dated 12/09/24 to 03/08/25 documented a primary diagnosis of Parkinson's and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #8 A plan of care dated 12/24/24 to 02/21/25 documented a primary diagnosis of Wernicke's encephalopathy and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #10 A plan of care dated 11/14/24 to 02/11/25 documented a primary diagnosis of sarcopenia and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #12 A plan of care dated 02/09/25 to 05/09/25 documented a primary diagnosis of cancer of the prostate and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #13 A plan of care dated 01/22/25 to 03/22/25 documented a primary diagnosis of Alzheimer's disease and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #14 A plan of care dated 11/11/24 to 01/09/25 documented a primary diagnosis of senile degeneration of the brain and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #16 A plan of care dated 12/31/24 to 03/30/25 documented a primary diagnosis of cancer of the bladder and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #17 A plan of care dated 12/16/24 to 03/15/25 documented a primary diagnosis of senile degeneration of the brain and showed no patient-specific individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 03/06/25 at 1:20 pm, Staff C stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 8, 10, 12, 13, 14, 16 and 17 failed to include patient-specific services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to develop a coordinated plan of care with the long-term care facility for two (Patients #6 and 9) of 19 patients reviewed. --- Patient #6 A plan of care dated 12/09/24 to 03/08/25 showed a primary diagnosis of Parkinson's disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. On 03/05/25 at 5:10 pm., Staff #1 (of long-term care facility #1) stated, there was no coordinated plan of care between the facility and the hospice. Patient #9 A plan of care dated 02/03/25 to 05/03/25 showed a primary diagnosis of chronic obstructive pulmonary disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. On 03/06/25 at 9:00 am., Staff #1 (of long-term care facility #2) stated, there was no coordinated plan of care between the facility and the hospice. On 03/06/25 at 1:35 pm., Staff C stated the plan of care for Patient #6 and 9 did not outline services to be provided by the long-term care facilities.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for thirteen (Patients #3, 4, 6, 7, 8 and 9) of thirteen patients reviewed. Findings: Patient #3 A plan of care dated 01/30/22 to 03/30/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A plan of care dated 01/13/22 to 03/13/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 04/15/22 to 07/13/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 01/10/22 to 03/10/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A review of the plan of care dated 02/12/22 to 04/12/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 01/05/22 to 04/04/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 05/4/22 at 10:50 am, Staff B stated the plans of care for Patients #3, 4, 6, 7, 8 and 9 failed to include services necessary for the palliation and management of the terminal illness.