Every finding on record at Thousand Oaks Hospice Inc.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 Patients #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting.

Upon patient record review, 4 of 14 (Patient #2, 3, 5, 6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: On 09/25/25, patient complained of SOB and productive cough. MD ordered Robitussin and Albuterol NMT's. Patient seen in follow up on 09/27/25 with continued labored breathing. No further f/u call or visit for 6 days. Patient #3: On 11/14/25, nurse reports that patient is exhibiting increased frequency of yelling, increased anxiety and agitation. Dr. ordered a new psychotropic med, Seroquel 25mg at bedtime. There was no evidence of a follow up call or visit to the patient for 7 days. Patient #5: On 11/14/25, caregiver called stating patient's blood pressure was low. The Dr. discontinued Quitiapine and Zyprexa feeling this may be lowering blood pressure. The Dr. gave a new order for micronized progesterone at bedtime. There was no evidence of a follow up call or visit to the patient for 7 days. Patient #6: On 10/31/25, Patient was complaining of a migraine and Acetaminophen was ineffective. The Dr. ordered Imitrex for treatment of headache. This patient is a 69 year old patient with history of cerebral infarct and cardiac diagnosis, there was no evidence of a follow up call or visit to the patient for 4 days.

Upon patient record review, 5 of 14 (Patients #1, 5, 7, 8, 10) 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: Patient is on Aspirin, There are no interventions or goals for bleeding precautions or use of anticoagulants. The patient is on Metformin, which is a hospice covered medication per record. There are no interventions or goals regarding diabetes or education of diabetic needs. The patient has depression and anxiety and there is no evidence of interventions or goals related to medications and education provided for management of anxiety and depression. Patient #5: The patient is on oxygen. There are no interventions or goals for use of oxygen. The patient has a nebulizer and suction machine in the home. Suction is being used regularly. There are no interventions or goals related to use of suction on the plan of care. Patient #7: The patient is admitted with chronic diastolic heart failure. The blood pressure on admit was 170/105. All but 2 nurse visits to the patient have involved a high blood pressure that included the systolic being over 150. The plan of care has interventions and goals for edema, however there is no evidence of any plan of care including interventions and goals for uncontrolled hypertension. This patient also has a code status listed as "undecided" there are no interventions or goals regarding advanced directives in the plan of care. Patient #8: The patient is on service with Alzheimer's disease and co morbidities of heart failure. There are no interventions or goals for cardiac. The patient is taking multiple medications for constipation, though there are no interventions or goals for GI or constipation. The patient was prescribed Micronized Progesterone for sleep at admission, there are no interventions or goals for insomnia. The patient also has no interventions or goals for management of pain. Patient #10: The patient was admitted as a full code. There is no interventions or goals related to advanced directives in the plan of care.

Upon patient record review, 4 of 14 (Patients #3, 4, 6, 8) 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 #3: During admission assessment the nurse identified DME including a bed (that the patient already had), wheelchair, nebulizer, suction, oxygen, and E tank. The nebulizer, suction, and oxygen are not on the patient plan of care. Patient #4: During admission assessment the nurse identified DME including a wheelchair, shower chair and oxygen with E tank (that the patient already had). The nurse also documented need to order a urinal. The wheelchair and shower chair as well as the urinal are not on the patient plan of care. Patient #6: During admission assessment the nurse identified DME including a low air mattress, hospital bed, bedpan, overbed table, cane, walker, wheelchair, shower chair, urinal, nebulizer, and suction, as well as oxygen with an E tank. The only DME listed on the patient plan of care is the oxygen and the E-tank. Patient #8: During admission assessment the nurse identified DME including a wheelchair and a hospital bed (that the patient already had). The nurse also documented need to order oxygen with an E-tank and a shower chair. The wheelchair, hospital bed, and oxygen with E tank are not on the patient plan of care.

Upon patient record review, 6 of 14 (Patient #2, 3, 4, 5, 6, 7) 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 #2: On 10/17/25, Patient was started on Augmentin for a UTI. There was no evidence of updates to the plan of care for infection or GU. Patient #3: On 11/14/25, Medications changed due to increased yelling and agitation. Seroquel was initiated. There was no update made to the plan of care regarding increased agitation and yelling requiring an additional medication. Patient #4: Patient has had several falls, with 2 occurring in November. There is no evidence of any updates made to the plan of care in regards to fall prevention. Patient #5: On 11/14/25, caregiver called with concerns of hypotension. medications were changed with the discontinuation of Seroquel and Zyprexa, and the addition of Micronized Progesterone. There is no evidence of updates in the plan of care. Patient #6: On 10/31/25, patient was prescribed Imitrex for severe migraines. There is no evidence of the plan of care being updated to reflect changes to medication and changes in, or addition of migraines. Patient #7: Patient consistently presenting with elevated blood pressure. The physician ordered Hydrazaline for prn use as well as adding Nifedipine for the patient daily. There was no evidence of an update to the plan of care. On 11/12/25, patient prescribed Zithromax for complaints of elevated temperature, and productive cough with green sputum. There is no evidence of an update to the plan of care in regards to infection and change in respiratory status.

Upon patient record review, 3 of 14 (Patients #1, 3, 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 #1: The patient is on Aspirin and does not have bleeding precautions on the aide assignment. The assignment states encourage fluids. The assignment states patient diet is as tolerated, however, the patient is on a mechanical soft diet. Patient #3: The assignment states encourage fluids. The assignment does not list a diet, however, the patient is on a mechanical soft diet. The aide assignment states, "bed bath or shower as tolerated. The use of “as tolerated” for any task, whether personal care or non-personal care tasks, are not acceptable. The aide does not have the scope of practice to determine which method of bathing to use and patient was not cognitively able to decide. Patient #5: The aide assignment states, "bed bath or shower as tolerated. The use of “as tolerated” for any task, whether personal care or non-personal care tasks, are not acceptable. The aide does not have the scope of practice to determine which method of bathing to use and patient was not cognitively able to decide.

Upon personnel record review, 1 of 13 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1: Upon review of the Administrators personnel record, there is a job description for a staff nurse in the personnel record. There is no evidence of a job description for the Administrator or for the DPCS designee.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance During the survey it was noted that several care plans were written/entered into the record by the LVN and is not within the LVN scope of practice.

Upon patient client record review, 1 of 14 (Patient #5) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #5: On 11/14/25, caregiver called stating patient's blood pressure was low. The physician gave a new order for micronized progesterone at bedtime. There was no evidence in the documentation of the new medication and if it was effective.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patients #11 and 12: The discharge summary did not include the patients current plan of care, latest physicians orders or medication list.