Every finding on record at Uni Care Hospice, Inc

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #10: Space allocated to confirm patient's choice or decision not to choose physician is left blank. Unable to verify

Upon patient record review, 1 of 19 (Patient #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 #6: 5/25/25 note regarding call from facility reporting hypotension of 76/39. PRN visit made shows bp 72/40. Next day, LVN noted call to facility with no answer and no follow up noted. 5/28/25 call from facility reported unable to give meds related to deep sleep. LVN made call to provide education. 5/29/25 RN visit made. BP 91/45. Per RN patient appears weak and tired, decreased energy and decreased ability to participate in activities, unable to bear weight at times. SpO2 recorded as 85% on room air. Respiratory system assessment documented - assessed no issue specified. Patient has order in place for Oxygen prn and order to notify MD SpO2<85%. Although there is previous documentation of patient's refusal of Oxygen, there is no re-education/reoffering related to current symptoms. Not seen again by nursing until 6/5/25.

Upon patient record review, 2 of 19 (Patient #1, 2) 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: Eliquis prescribed with no bleeding precautions identified in problems, goals, interventions. patient #2: Oxygen prescribed with no Oxygen related problems, goals, interventions including no safety precautions.

Upon patient record review, 2 of 19 (Patient #3, 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 #3: 9/26/25 Treatment order as needed for any new skin tears: Cleanse with wound cleanser. Pat dry. Cover with border gauze. Notify hospice. Patient #7: 5/9/25 Order to apply Bacitracin topical antibiotic ointment to open wounds daily, (without specifying wound locations). 4/24/25 order for Foley catheter, change monthly, without specifying catheter/balloon size and or circumstance for change. corrected on site

Upon client record review, 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: 5/5/25 SN visit: 16 fr. Foley discontinued and new one placed. 5/20/25 SN visit: A 16 fr. Foley was replaced today. No orders for 16fr. foley to be used. Corrected on site

Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7: Competency form utilized by agency for hospice aide lists shampoo only not specifically sink, tub, and bed.

Upon patient record review, 6 of 19 (Patient #1, 2, 3, 7, 8, 10) 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: Patient on Eliquis since admission, but bleeding precautions is not marked for Hospice Aide assignment. Aspiration precautions are marked. Encourage fluids as tolerated if not contraindicated is marked. There is an order for Nectar Thickened Liquids not noted on aide assignment. Patient #2, 3, 7: Oxygen section is blank, although patient has order for prn Oxygen. Patient #8: Oxygen flow rate addressed, but not Oxygen related safety precautions. Patient #10: Colostomy care assigned every visit as needed. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable

Upon patient record review 1 of 19 (Patient #2) 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: 5/1/25 Hospice Aide frequency 2x/wk. Only 1 visit week of 5/27/25 (on 5/27).

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. Volunteer service provided was less than 5 percent requirement of total patient care hours per agency's documented tracking report for 2024.

Upon personnel record review, 1 of 19 (Personnel #13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #13: No evidence of orientation to hospice philosophy. (PT has made visits in distant past per staff).

Upon patient client record review, 1 of 19 (Patient #10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #10: Admitted 2/6/25 I choose and I do not choose attending physician are both blank in the election.

Upon patient client record review, 2 of 19 (Patient #6, 7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6: Per CTI: (Patient name) is an 89 year old female with a hospice eligible dx of bladder carcinoma. She had been on hospice services but revoked upon transport to the ER following a fall. Interview with RN identifies that physician was mistaken. Patient did not revoke hospice but was discharged upon transport to ER by facility without hospice contact/authorization. Patient #7: Foley catheter changes 5/5 and 5/20/25. 5/5/25 visit: 16 Fr Foley discontinued and new one placed. 5/20/25 SN visit: A 16 Fr Foley was replaced today. Neither note included specifics of procedure including balloon size and or deflating prior to removal. Documentation was updated with details, during survey.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Upon observation, the actual policy is not provided to patients at time of survey. Staff implemented corrective action plan prior to end of survey.

Upon client record review, 2 of 19 (Patient #1, 2) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1,2: Initial comprehensive and consent/admission forms do not include documentation to verify discussion.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients the nurse surveyor noted that for HOSHV#3/RR#3, the Chaplain and the Social Worker did not complete the comprehensive assessment within five calendar days of the election of hospice care. There was no documentation in the electronic medical record to indicate why this was not completed. This was verified by the Regional Director of Operations.

Observed in Record Review. In 10 of 10 patient records reviewed, for active records, it was noted by the nurse surveyor that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, HOSRR#4, HOSRR#5, HOSRR#6, HOSRR#7, HOSRR#8, HOSRR#9 and HOSRR#10 the goals were not measurable or individualized for the patients. For example, Optimal bowel elimination and comfort and Altered skill will heal to maximum potential.” Additionally, there were no goals for the chaplain or social worker and most goals in the records from the El Centro office were set to be achieved at the end of the certification period. Findings were verified by the Regional Director of

Observed in Patient Home. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that for HOSRR#4, oxygen was ordered prn to treat the patient's sudden onset of shortness of breath, however the plan of care was not updated to reflect this change. Findings were verified with the Regional Director of Operations.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients it was noted by the nurse surveyor that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, HOSRR#4, HOSRR#5, HOSRR#6, HOSRR#7, HOSRR#8, HOSRR#9 and HOSRR#10 the visit frequency as established by the IDG (interdisciplinary group) included PRN visits for the registered nurse, chaplain and the social worker; however, the extra PRN visits were not qualified with a reason for making them as required by regulation. Additionally, additional skilled nursing visits though qualified, they were open ended and not quantified. Findings were verified by the Regional Director of Operations.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HOSHV#1/RR#1 the hospice aide washed her hands with soap and water in the patient’s sink then put on a gown, changed her mask and then put gloves on without hand sanitizing. She then went in and out of her bag and set up the bathing supplies to include getting the water pans filled and disrobing and draping the patient all with the same pair of gloves on. During HOSHV#2/RR#2 with a skilled nurse, proper hand technique was broken. The nurse removed her gloves several times without hand sanitizing and touched other objects such as the bed controls, then hand sanitized and put clean gloves on. During the dressing change, she removed the old dressing, cleaned the wound, and applied a clean dressing all with the same pair of gloves on. During HV#3, the chaplain did not hand sanitize upon entering the home, after signing in at the register, after talking briefly with the patient, or upon leaving the home. When asked if she had hand sanitizer, she replied that she keeps it in her car. The Regional Director of Operations was present during the home visits and also observed the breaks in technique per agency policy.

Observed in Record Review. In 5 of 9 patient records reviewed, for active patients with the hospice aide; the nurse surveyor noted that for HOSHV#3/RR#3 the hospice aide care plan had not been updated based on changes in the patient condition. On admission the patient was to have a shower, she is now bed bound and getting a bed bath. HOSRR#5, the patient had a large dressing and a colostomy, the hospice aide care plan did not contain any instructions for the aide regarding her responsibility in their care. HOSRR#6 and HOSRR#7, both patients were on oxygen and there were no instructions in the hospice aide care plan regarding the oxygen. HOSRR#8 the patient had a gastrostomy tube and there were no instructions regarding its care in the hospice aide care plan. Findings were verified by the Regional Director of Operations.

Observed in Infection Control System Tracer. In 1 of 10 HR files reviewed, it was noted by the nurse surveyor that for HR#4 (Chaplain) there were no initial competencies completed at time of hire almost two years ago. This was verified by the Regional Director of Operations and the Office Manager.