Every finding on record at Sunset Hospice, LLC

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed of patients who received Hospice aide (HA) services, the agency did not ensure that HA services were provided as ordered and included in the plan of care. CLINICAL RECORD 8: The patient elected hospice services on 02/04/2026 with a diagnosis of Malignant Neoplasm Upper Lobe Left Lung or Bronchus. The HA plan of care dated 02/04/2026 ordered HA services for Bed Bath every visit if ALF (assisted living facility) has not met need. The HA visited on 02/09/2026. There was no documented evidence of a bed bath provided by the HA or by the ALF. CLINICAL RECORD 10: The patient elected hospice services on 12/24/2025 with a diagnosis of Malignant Neoplasm of Pancreas unspecified. The HA plan of care dated 12/24/2025 ordered a Shower 2-3 times a week. The HA visited the patient from 01/09/2025 to 01/13/2025. There was no documented evidence of a shower completed for the entire week. CLINICAL RECORD 11: The patient elected hospice services on 06/17/2025 with a diagnosis of Moderate Protein Calorie Malnutrition. The HA plan of care dated 06/17/2025 ordered a Bed Bath every visit if facility has not completed; Shower weekly if facility has not completed. There was no documented evidence of a bed bath or shower provided by the HA or facility for the entire week of 08/04/2025 to 08/08/2025. CLINICAL RECORD 12: The patient elected hospice services on 02/28/25 with a diagnosis of Parkinson's Disease. The HA plan of care dated 02/28/2025 ordered a Bed Bath every visit 2 times a week; Shower by VA CNA Monday, Wednesday, and Friday. The HA visited the patient on the week of 05/4/2025 to 05/13/2025. There was no documented evidence of a bed Bath or shower provided by the HA or VA CNA. During a joint clinical record review and interview on 02/19/2026, the Clinical Director agreed there was no documented evidence that the HA provided services as ordered and included in the plan of care. The Clinical Director stated that the HA should follow the plan of care and, if unable to notify the Registered Nurse (RN).

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits, review of the medication reconciliation performed during the visit revealed the agency did not ensure that all medications taken by the patients were documented in the clinical record and included in the medication regimen review to assess for drug interactions and side effects. The agency's policy, "2-004 Medication Profile", revised November 2021 stated in part: (2) A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. The review will identify drug/food interactions. ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy/ The interdisciplinary group will confer with an individual with education in drug management to ensure the drugs and biologicals meet the patient needs. (3) During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as clinicians, understand the medication regimen. This includes, but will not be limited to (A) using the medication profile to evaluate the use of drugs in the home setting". Home Visit 2: This patient elected their hospice benefit on 12/28/2022 and resides in an assisted living facility (ALF). During a home visit observation conducted on 3/7/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the medication profile located in the Assisted Living Facility. This review revealed the ALF's medication profile contained orders for: "Tylenol 500 mg, Take two (2) tabs orally two times (2X's) daily"; "Fleets Glycerin Suppository, Insert one (1) suppository every day as needed (PRN) for constipation; and "Quetiapine 50 MG. Take one quarter (1/4) tablet orally as needed (PRN) for agitation for a total of Quetiapine 12.5 mg". The hospice agency's medication profile did not contain documentation of the patient's use of Tylenol 500 mg, the Fleets Glycerin Suppository, and Quetiapine 50 MG, and therefore did not include these medications in the review of the patient's medication regimen for side effects and drug interactions. A joint record review and interview on 3/7/2023 with the Director of Clinical Services confirmed the ALF medication profile did not match the hospice organization's medication profile.