Every finding on record at Sunset Hospice LLC

Upon patient record review, 2 of 14 (Patient #1,9) 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: Upon patient record review the initial nursing assessment stated the patient had multiple hospital admissions in past 6 months for elevated blood sugar and UTI. There was no problem/intervention/goals for infection. Patient #9: Upon patient record review there was an initial nursing assessment note on 5/18/25 noting the patient had a foley catheter. There was no plan of care problem/intervention/goals for foley catheter.

Upon patient record review, 2 of 14 (Patient #3,9) 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: Upon patient record review there was a nurse note on 6/2/25 "is now requiring compression and elevation related to edema. There was no order for compression. Patient #9: Upon patient record review there was an initial nursing assessment note on 5/18/25 noting the patient had a foley catheter. There was no order for foley catheter.

Upon patient record review, 2 of 14 (Patient #3,6) 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 #3: Upon patient record review there was a nurses note on 6/2/25 "is now requiring compression and elevation related to edema. The plan of care was not updated to address edema. Patient #6: Upon patient record review there was an order on 5/11/25 for Cephalexin 50 mg. The plan of care was not updated to address infection.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No Governing Body minutes for 2024 mentioned the frequency and detail of data collection.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. No Governing Body minutes for 2024 mentioned the QAPI program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No Governing Body minutes for 2024 mentioned the QAPI program.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: Upon patient record review there was an initial nursing assessment note on 5/18/25 noting the patient had a foley catheter. The aide plan of care did not identify the patient had a foley catheter. Additionally, the nurse noted on 5/20/25 the patient had seizures. Seizure precautions was not on the Aide plan of care

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer hours documented for 2024 was 3.3%.

Upon patient record review, 5 of 9 (Patient #1, 2, 3, 6, 7) 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: The psychosocial assessment noted numerous psychosocial needs including assistance with bills, end of life, body donation arrangements, anxiety related to financial concerns, and care needs; however there was no evidence of a psychosocial plan of care to address identified problems with goals and interventions. Patient #2: No evidence of nursing or spiritual care plans related to identified problems to include goals and interventions. No evidence of an updated comprehensive assessment by nursing and spiritual care that updated progress toward goals and outcomes. Patient #3 No evidence of an updated comprehensive assessment that updated progress toward goals and outcomes. Patient #6: No evidence of nursing care plans for identified problems with goals and interventions. No evidence of an updated comprehensive assessment by nursing and spiritual care that updated progress toward goals and outcomes. Patient #7: No evidence of spiritual care plan for identified problems with goals and interventions. During the chaplains comprehensive assessment it was noted that needs per family were prayer, reading of scriptures and spiritual counsel.

Upon client record review, 1 of 9 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The social worker completed visits on 6/24 PRN and 6/28, no evidence of an order for these visits.

Upon patient record review 1 of 8 applicable (Patient #1) 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 #1: order on 6/16 for aide frequency of 3x/week. Aide visits on 6/29 began as daily. No order for daily aide visits.