Every finding on record at Unified Hospice Services, Inc.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was record of an agency earthquake drill on 10/19/24. The only other evidence present of an additional exercise completed was the 2022 "Great California Shake out." There was no documented evidence of any additional exercise conducted during the 2023 calendar year or in 2025 to date.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Documentation present on the plan of care recorded an incomplete lab order, "Blood work with Albumin level, PT/INR, PTT, and Ammonia level." The start date of the entry was indicated as 10/17/25. There is no documented evidence present of a SN visit that day to obtain the ordered lab tests.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. No evidence was found of ongoing efforts to recruit or retain volunteers.

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. There was no documented evidence of any utilization of volunteers for the 2024 calendar year.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group consider changes that have taken place since the initial assessment no less frequently than every 15 days. For example: on review of RR#5 the patient revoked the hospice benefit and was discharged from hospice, however there was no documentation of an IDG meeting to review the patient's changes after the patient discharge. This observation was reviewed with the Field RN and the Office Manager.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure that plan of care revisions were based on information from updates to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. For example: upon review of RR#4 the plan of care had many goals with achieve by dates that were past yet no progress toward goals and outcomes had been documented. Such as: Caregiver will be educated on patient's hygiene needs including incontinent care by 3/3/23, Family and patient caregiver will verbalize understanding of functional limitations as part of terminal condition and disease process through education of hospice philosophy by 2/27/23, and No observable signs of presence of discomfort by 2/27/23. RR#5 has similar goals with achieve by dates that were past with no documentation of progress toward the goals such as: Patient/Family will verbalize understanding of non-pharmacological pain management and prevention technique by 9/23/22, SOB symptom will be alleviated during ambulation by 9/23/22 and Patient will tolerate ADL's without any signs and symptoms of pain and discomfort by 9/23/22. The patient was discharged on 10/5/22 without any documentation of progress toward the established goals. These observations were reviewed with the Field RN, and Office Manager.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient record contained information that reflected the patient's care, treatment, and services. For example: upon review of RR#5 the documentation noted that the patient had multiple hospitalizations in the last six months, however no documentation of the H&P from the hospitalizations was noted to be included in the patient record. This observation was reviewed with the RN Field Nurse, and Office Manager.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient record reflected the patient's care, treatment and services. For example: on review of HV#1 the SN documentation on week 2 noted the patient's pain regimen was Acetaminophen and Voltaren Gel yet the patient was documented to be taking Ibuprofen and Baclofen for pain. This observation was reviewed with the RN Field Nurse.