Every finding on record at Vega Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #1) 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 initial RN assessment there is documentation that the patient has a APP mattress, Nebulizer, hospital bed, and over the bed table. These items are not listed on the plan of care/DME. Corrected on site.

Upon client record review, 2 of 14 (Patient #4, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: On the SN assessment 09/30/25 there is documentation, "Right heel ulcer observed; wound care completed", there is not an order for wound care on the plan of care. Corrected on site. Patient 10: On the admission order there is spiritual care ordered for spiritual assessment within 5 days of admission to identify spiritual needs/support to patient, family, and primary caregiver for the benefit period. There was not an assessment documented within 5 days of admission by SC.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 4: On the SN assessment 09/30/25 there is documentation, "Right heel ulcer observed; wound care completed", the SN did not document how the patient tolerated the wound care.

Upon patient client record review, 1 of 14 (Patient #4) 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 4: On the SN assessment 09/30/25 there is documentation, "Right heel ulcer observed; wound care completed", the SN did not document the order for the wound care in past tense to include specific details performed for wound care.

Upon patient record review, 11 of 11 (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: The section of consent/election to identify patient choice of physician has two options. Either check Box 1 "I wish to choose my primary physician for my medical care not related to hospice care." and/or Box 2 "I want to use Hospice Physician." There is no clear option for patient to choose their attending MD for hospice care. The Medical Director's name and information is provided.

Upon patient record review 1 of 11 (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3: There is no evidence of SC visit/assessment within 5 days. Spiritual assessment completed on SC 10/13/22.

Upon patient record review, 1 of 11 (Patient #1) 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 #1: Initial MD Order 8/3/22 for frequency of MSW and SC eval within 5 days. Initial POC identified SW and SC frequency of 1/mo and 1 PRN. Patient refused MSW assessment visit and refused any additional SC visits after the SC 8/5/22 evaluation visit. POC continued to have goals and interventions for psychosocial and spiritual care even though they were no longer involved in the patient's care.

Upon client record review, 1 of 11 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Order for SC to visit/eval within 5 days. There was no SC visit until 10/13/22 and there is no updated frequency order consistent with the one time visit at that time.

Upon personnel record review, 1 of 1 applicable (Personnel # 4) 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.) ·(C) Shampoo, sink, tub, and bed Personnel #4: The competency checklist utilized by the agency does not differentiate the types of shampoo; therefore, cannot validate that sink, tub and bed shampoo types were demonstrated/validated.

Upon patient client record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) 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 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: The section of consent/election to identify patient choice of physician has two options. Either check Box 1 "I wish to choose my primary physician for my medical care not related to hospice care." and/or Box 2 "I want to use Hospice Physician." There is no clear option for patient to choose their attending MD for hospice care. The Medical Director's name and information is provided.