Every finding on record at Urban Hospice Care, Inc.

Upon patient record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10,13,14: The RN comprehensive assessment the RN does not take into consideration the imminence of death.

Upon patient record review, 4 of 14 (Patient #1,2,5,10) 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 Patient 1: Upon the home visit the patient had medications, Benzonatate 100mg, Loperamide 2mg, these medications were not listed on the medication profile. Corrected on site. Patient 2: On the patient medication profile there is an order for Zofran 4mg ODT 1 tablet every 6 hours as needed, upon home visit the patient did not have Zofran ODT in the home, patient has Zofran 4mg/5ml every 8 hours as needed in the home. On the home visit the patient is taking Vitamin D3 1000IU two times daily, this medication was not listed on the patient's plan of care. Corrected on site. On the medication profile there is Carbidopa/Levodopa 10mg-100mg tablet route is oral, frequency is three times a day via G-tube. The patient is NPO and the route should be G-tube. Corrected on site. Patient 5: On 7/24/25 Zithromax Z-PAK was ordered for 5 days, this remains active on the patient medication list. Corrected on site. Patient 10: On the medication list there is an order for Acetaminophen /codeine 300/600mg 1 tablet two times daily and Acetaminophen 650mg 1 suppository every 4 hours as needed, there is not a daily maximum limit for these ordered medications.

Upon patient record review, 3 of 14 (Patient #4,6,13) 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 4: On the patient plan of care there is an order for Aspirin 81mg enteric coated one every other day. There is not a risk for bleeding on the patient plan of care with goals or interventions. Corrected on site. Patient 6: On the patient medication profile there is an order for Aspirin 81mg chewable daily, there is not a risk for bleeding on the plan of care with goals and interventions. 13: On the plan of care there is an order for Aspirin 81mg daily and Eliquis 2.5mg daily, there is not a risk for bleeding on the plan of care with goals and interventions.

Upon patient record review, 4 of 14 (Patient #1,2,7,10) 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 1: Upon the home visit the patient had medications, Benzonatate 100mg, Loperamide 2mg, these medications were not listed on the patient's plan of care. Corrected on site. Patient 2: On the patient plan of care there is an order for Zofran 4mg ODT 1 tablet every 6 hours as needed, upon home visit the patient did not have Zofran ODT in the home, patient has Zofran 4mg/5ml every 8 hours as needed in the home. On the home visit the patient is taking Vitamin D3 1000IU two times daily, this medication was not listed on the patient's plan of care. Corrected on site. On the POC there is Carbidopa/Levodopa 10mg-100mg tablet route is oral, frequency is three times a day via G-tube. The patient is NPO and the route should be G-tube. Corrected on site. Patient 7: On the RN comprehensive assessment there is documentation that the patient is on 2 liters per minute of oxygen prn, there is not an order for oxygen on the plan of care. Patient 10: On the plan of care there is an order for Acetaminophen /codeine 300/600mg 1 tablet two times daily and Acetaminophen 650mg 1 suppository every 4 hours as needed, there is not a daily maximum limit for these ordered medications.

Upon patient record review, 5 of 14 (Patient #1,2,3,4,7) 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 equipment and supply needs. Patient 1: On the RN comprehensive assessment the RN documented, patient has walker and wheelchair, O2 concentrator and E-tank, these items are not listed on the plan of care. Corrected on site. Patient 2: On the RN comprehensive assessment there is documentation that patient has air mattress, bed, Hoyer lift, enteral pump machine, the need for E-tank and suction machine, these items are not listed on the plan of care. Corrected on site. Patient 3: On the RN comprehensive assessment there is documentation that the patient has a bed, over the bed table, walker, wheelchair, shower chair, nebulizer, suction machine, O2 concentrator and E-tank. These DME items are not listed on the patient’s plan of care. Corrected on site. Patient 4: On the Face to Face the physician documented, “Sits in Barton chair” there is not a Barton chair listed on the plan of care. Corrected on site. Patient 7: On the RN comprehensive assessment there is documentation that the patient needs a bed, air mattress, over the bed table, wheelchair, nebulizer, suction machine, O2 concentrator, E-tank, these needed items are not on the plan of care.

Upon client record review, 2 of 14 (Patient #3,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: On the RN comprehensive assessment, the SN documented, "re wrapped right leg with splint, instructed patient son regarding neurovascular checks including checking of toes for temperature, capillary refill, the plan of care does not contain orders for splint care or how often to wrap the splint. Patient 11: There is evidence in the discharge summary noting patient death 11/6/24 along with destroying controlled substances, however there is no documentation of visit being made in the record.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 11: There is no evidence the 8/6/25 letter has been sent to the bereaved family member up to one year following the death of the patient.

Upon patient record review, 8 of 14 (Patient #3,5,6,7,8,9,13,14) 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 3: On the current aide plan of care there is an order to turn and reposition, record bowel movements, encourage fluids as tolerated if not contraindicated, change patients linens, these orders do not contain a frequency. Corrected on site. Patient 5: On the recent aide plan of care 5/29/25, there is an order to turn and reposition, record bowel movements, dress street clothes, change patient linens, these orders do not contain a frequency on the aide plan of care. Corrected on site. Patient 6: On the aide plan of care there is an order for record bowel movements, dress street clothes, change patient linens, these orders do not contain a frequency. Patient 7: On the aide plan of care there is an order for turn and reposition, record bowel movements, dress street clothes/pajamas/gown, encourage fluids as tolerated if not contradicted, these orders do not contain a frequency. Patient 8: On the aide plan of care there is an order for turn and reposition, record bowel movements, dress street clothes/pajamas/gown, encourage fluids as tolerated if not contradicted, these orders do not contain a frequency. Patient 9: On the aide plan of care 8/27/24 there is an order to turn and reposition, record bowel movements, dress street clothes, these orders do not contain a frequency. Patient 13: On the aide plan of care there is an order for chair to bed, record bowel movements, dress street clothes, change patient linens, these orders do not contain a frequency. Patient 14: On the aide plan of care there is an order for record bowel movements, dress street clothes, these orders do not contain a frequency.

Upon patient client record review, 1 of 14 (Patient #2) 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 2: On the SN assessment 8/26/25, “Patient G-tube site is intact, dry and no signs of infection, dressing changed provided”, the documentation does not contain details of the wound care and is not complete and clear. Corrected on site.

Observed in Record Review. In 3 of 3 patient records reviewed, Hospice surveyor noted the IDG care plans did not include any problems or goals related to spiritual care. The nursing goals were not measurable . For example, in RR#1, the goal was patients blood pressure will be within normal limits ,but did not define what normal limits are for this patient. A second goal stated Pain will remain in comfortable level The goals did have time frames set for completion. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide state specific laws on Advance Directives as required. During HV#1, HV#2, and HV#3 the surveyor did not find this information in patients’ home folders, nor was there documentation in the records that this was discussed with patients and families. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, comprehensive reassessments were not documented by an RN every 15 days or less. The EMR template that was used did not include all required components. This was reviewed with the Administrator/DPCS.

Observed in Patient Home. In 1 of 2 home visits conducted, where registered nurses were observed, an RN did not perform medication reconciliation during HV#1, which is required to be done at every visit according to the Medication Profile policy 4-050.1. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, pre-bereavement assessments and post-bereavement assessments were not documented in patients’ records. The templates were blank and narrative notes provided no assessment information. The same was true in five of five post death bereavement assessments. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, interdisciplinary group meeting notes did not have revised comprehensive assessments that included decline, progress towards desired outcomes and goals. In addition, plans for the following two weeks were not specific. This was reviewed with the Administrator/DPCS. Observed in Record Review. In 13 of 13 patient records reviewed, interdisciplinary group meeting notes did not document decline since the previous meeting, nor include clinicians’ plans for upcoming visits until the next meeting. This was found in entries by the Social Worker and Spiritual Coordinator and was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, the plans of care were not comprehensive. Spiritual care and social work did not document any goals, and nurse's goals did not include metrics by which to measure progress. As well, there were no target dates for completion in the nursing goals. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that orders were incomplete. In every record there were orders for additional prn visits without routine visits scheduled; and prn visits that did not specify the frequency and/or rationale for these additional visits. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, members of the interdisciplinary group did not review and revise plans of care as frequently as patients’ conditions required, but no less than every 15 days. The same documentation was repeated by the Social Worker in most notes. The narrative was the same and did not address patient needs or decline. And the Spiritual Coordinator documented in every initial comprehensive assessment and reassessment that spiritual services were not needed by patients or families, thus there were no notes written by this service. This was reviewed with the Administrator/DPCS.

Observed in Patient Home. During medication reconciliation at HV#2 the surveyor learned that a comfort kit was ordered but was never delivered. According to B&C staff, another hospice nurse explained that it wasn’t necessary to have the kit in the home until the patient began actively dying. This was reviewed with the Administrator/DPCS. Observed in Record Review. In 13 of 13 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to his or her individualized plan of care. In every record the Spiritual Counselor did not visit patients. Rather, he documented that the visits were not necessary. The Social Worker did not consistently see patients as ordered, and the and Volunteer Coordinator never made visits as ordered. This was reviewed with the Administrator/DPCS.

Observed in Tracer Activities. During review of bereavement services and discussion with leaders, it was learned that the organization failed to develop an organized program. Although there was a documented tracking log there was no evidence of specific procedures for an organized bereavement program including: development of a bereavement plan of care based on identified risks; specific time frames for contacting the bereaved through phone calls, visits and/or mailings; or resources including grief support groups or available counseling services for the bereaved. This was discussed with the organization’s leaders. This was reviewed with the Administrator/DPCS. Observed in Document Review. The individual providing bereavement services was not a qualified professional with experience or education in grief or loss counseling. This was reviewed with the Administrator/DPCS.

Observed in Tracer Activities. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: §418.54, §418.56, and §418.100. This was discussed with the Administrator/DPCS.

Observed in Patient Home. During observation of medication reconciliation at HV#2 it was noted that the patient’s medication list had not been revised since admission four months prior. There were handwritten notations of changes for some medications. There were dosage and frequency inaccuracies for some of the drugs listed. Hospice nurses were unaware that a standard of practice is to provide a new list whenever changes are made.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not identify potential safety risks in patient’s homes. During HV#1 and HV#2 the surveyor observed that an M-34 oxygen cylinder was stored in a closet with the door closed and was not addressed by staff during the visit. This was reviewed with the Administrator/DPCS.

Observed in Document Review. According to the Administrator/DPCS, the organization’s CLIA certificate had not been revised with the name of the person responsible for oversight since 2015. During this survey the organization contacted CMS through the Lab Excellence mailbox to get a new certificate. They contacted the California Department of Public Health and left a message after being referred there by CMS.