Every finding on record at Vista Hospice Care, LLC

Upon patient record review 1 of 19 (Patient #4) 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 4: The initial spiritual assessment was completed 8/19/25 with start of care 7/31/25.

Upon patient record review, 8 of 19 (Patients #1,#2,#3,#6,#10,#11,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: During home visit medication reconciliation, the patient's wife stated the patient is no longer taking diazepam and Miralax PRN medications, and takes senna PRN, not twice daily per medication orders. There was no evidence the agency updated the medication profile. Patient 2: During home visit medication reconciliation the facility and hospice medication profiles did not match. The facility contained acetaminophen 500mg every 8 hours PRN instead of three times daily PRN per hospice and has levothyroxine 50mcg daily and lidocaine 3% cream PRN not on hospice. The hospice medication profile also contained oxygen with no delivery method. Corrected on site with order clarification and medication profile update. Patient 3: The medication profile contained two differing frequencies of meclizine twice daily and three times daily. Corrected on site with order clarification and medication profile update. Patient 6,11: The medication profile contained oxygen with no delivery method. Corrected on site with order clarification and medication profile update. Patient 10: The medication profile contained two differing scheduled lorazepam doses of 1mg tablet every 6 hours and 0.35ml of 2mg/ml every morning. Corrected on site with order clarification and medication profile update. Patient 12: During home visit medication reconciliation the facility and hospice medication profiles did not match. The facility contained acetaminophen 500mg tablets, 2 tablets every 6 hours PRN and 1 tablet every 6 hours PRN instead of 2 tabs every 8 hours PRN per hospice, and has ondansetron 4mg every 6 hours PRN not on hospice, and facility does not have benazepril 40mg daily that is on hospice profile. Corrected on site with order clarification and medication profile update. Patient 13: During home visit medication reconciliation the facility and hospice medication profiles did not match. The facility does not have lorazepam PRN and nystatin oral solution on hospice, and the facility had guaifenesin liquid 100mg/5ml take 10ml every 4 hours PRN instead of 600mg ER tablet twice daily scheduled per hospice. The hospice profile also contained oxygen with no delivery method. Corrected on site with order clarification and medication profile update.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: The initial bereavement assessment was completed 9/11/24 with start of care 9/5/24.

Upon patient record review, 1 of 19 (Patient #7) 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 7: There was no evidence of weekly wound measurements and assessments per agency policy since 11/5/25.

Upon patient record review, 2 of 19 (Patients #1,#14) 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: The medical record contained orders for Eliquis since admission. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Corrected Patient 14: The plan of care contained active problems, goals, and interventions related to oxygen use. There was no evidence of oxygen orders or documentation regarding oxygen use. After agency investigation, the patient never had oxygen. Corrected on site with plan of care update.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 12: The medical record contained an order for social worker visits 3 PRN. There was no evidence of an anticipated need for services. Corrected on site with order clarification.

Upon patient record review, 7 of 19 (Patients #1,#2,#6,#10,#11,#12,#13) 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: The medical record contained nursing documentation since admission identifying patient has a suprapubic catheter. There was no evidence of an order for catheter type, size, and change frequency. Corrected on site with order received. During home visit medication reconciliation, the patient's wife stated the patient is no longer taking diazepam and Miralax PRN medications, and takes senna PRN, not twice daily per medication orders. There was no evidence the agency updated physician for orders to discontinue or change based on use. Patient 2: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had an order for acetaminophen every 8 hours PRN instead of three times daily PRN per hospice order and has levothyroxin daily and lidocaine 3% cream PRN that were not in hospice orders. The hospice record also contained an order for oxygen with no delivery method. Corrected on site with order clarifications. Patient 6,11: The medical record contained orders for oxygen with no delivery method. Corrected on site with order clarification. Patient 10: The medical record contained differing orders for two scheduled lorazepam doses of 1mg tablet every 6 hours and 0.35ml of 2mg/ml every morning. Corrected on site with order clarification. Patient 12: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had an order for acetaminophen 500mg tab, 2 tablets every 6 hours PRN and 1 tablet every 6 hours PRN instead of 2 tabs every 8 hours PRN per hospice order and has ondansetron 4mg every 6 hours PRN not on hospice orders, and facility does not have benazepril 40mg daily that is on hospice orders. Corrected on site with order clarification. Patient 13: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility does not have lorazepam PRN and nystatin oral solution on hospice orders. The facility also had an order for guaifenesin liquid 100mg/5ml take 10ml every 4 hours PRN instead of 600mg ER tablet scheduled twice daily per hospice order. The hospice medical record also contained an order for oxygen with no delivery method. Corrected on site with order clarification.

Upon patient record review, 4 of 19 (Patients #3,#7,#8,#13) 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: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer and low air loss mattress. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 8: The medical record contained nursing documentation 11/4/25 identifying patient use of a fall mat. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 13: The medical record contained nursing documentation upon recertification 10/6/25 identifying patient use of a bolstered mattress and nebulizer. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received.

Upon patient record review, 5 of 19 (Patients #1,#2,#3,#8,#12) 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: The medical record contained nursing documentation 9/23/25 identifying patient fall. There was no evidence the plan of care was updated to include problems, goals, and interventions related to fall safety. Corrected on site with plan of care update. Patient 2,3,12: The plan of care contained active problems, goals, and interventions to be completed by the social worker. The patients did not received social work services. Corrected on site with plan of care updates. Patient 8: The plan of care contained two active code statuses of full code and DNR. The record contained a signed DNR order. There was no evidence the plan of care was updated to discontinue the full code status. Corrected on site with plan of care update.

Upon client record review, 2 of 19 (Patients #1,#2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained nursing documentation 10/31/25 identifying the nurse completed a catheter change with no evidence of order. Patient 2: The medical record contained an order for nurse visit frequency of twice weekly. Missed documentation for a visit stated visit was not made due to nurse injury. There was no evidence of agency attempt to meet frequency as ordered.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 12: The medical record contained nursing documentation regarding an incident with skin tear during transfer 10/27/25. There was no evidence of investigation of the incident. Corrected on site with investigation completed and documented.

Upon patient record review, 1 of 19 (Patient #17) 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 Patient 17: There was no evidence of bereavement care plan tasks to send 3 and 6 month bereavement letters were completed.

Upon patient record review, 3 of 19 (Patients #2,#8,#9) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 2: During home visit observation, the patient required a lift for transfers. There was no evidence of instructions to utilize a lift for transfers on the aide care plan. Corrected on site with aide care plan update. Patient 8,9: The medical record contained nursing documentation since admission identifying patient need for max assist 2 with transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site with aide care plan update.

Upon patient record review 1 of 19 (Patient #7) 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 Patient 7: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 9/22/25.

Upon patient client record review, 2 of 19 (Patients #1,#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: The election form identified the patient elected to receive the Notification of Hospice Non-Covered Items upon admission 9/16/25. There was no evidence the patient received the requested addendum. Patient 11: The election form identified the patient elected to receive the Notification of Hospice Non-Covered Items upon admission 6/19/25. There was no evidence the patient received the requested addendum.

Upon patient client record review, 1 of 19 (Patient #18) 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 18: There was no evidence the QIO identification and contact information was provided on Notification of Medicare Non-Coverage prior to discharge as this information was not completed by agency on NOMNC form.

Upon patient record review, 4 of 13 (Patient #4, #7, #8, #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. Patient #4, #7-The medication profile indicates MiraLax 17gm oral powder every day as needed. It does not include specific instructions to include a diluent. (corrected on site) Patient #8-The medication profile indicates loperamide 2mg oral tablet for diarrhea prn administer per box label. It does not include specific instructions for dosage and frequency. (corrected on site) The RN visit note dated 9/28/22 indicates the patient has scrotal itching and the spouse is using an antifungal cream. This medication is not on the medication profile. The RN visit note dated 10/31/22 indicates the the RN applied anti-itch cream with lidocaine. This medication is not on the medication profile. Patient #10-On 09/30/22 orders were received for oral Morphine 100mg/5ml 20mg/ml .25 ml q4h prn pain. The medication profile was updated with Morphine 100mg/5ml 20mg/ml .25 ml q4h scheduled for pain.

Upon patient record review, 3 of 13 (Patient #2, #4, #8) 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 #2-The RN visit note dated 11/23/22 indicates the RN attempted to place a foley catheter, unsuccessfully, due to urinary issues. The plan of care was not updated with goals/interventions and does not reflect this identified problem. Patient #4-There is a physician's order dated 11/15/22 for wound care to a left forehead skin tear. The plan of care was not updated with goals/interventions and does not reflect this identified problem. Patient #8-Beginning 9/28/22, it is documented in RN visit notes that the patient is experiencing ongoing and severe itching of several areas of the skin. There are physician's orders on 10/19/22 and 10/24/22 for medications indicated for itching. The plan of care was not updated with goals/interventions and does not reflect this identified problem.

Upon patient record review, 3 of 13 (Patient #4, #7, #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 specific orders for all medications. Patient #4-The plan of care dated 10/13/22 indicates MiraLax 17gm oral powder every day as needed. It does not include specific instructions to include a diluent. Patient #7-The plan of care dated 10/13/22 indicates MiraLax 17gm oral powder every day as needed. It does not include specific instructions to include a diluent. (corrected on site) Patient #8-The orders dated 9/17/22 to update the plan of care indicates loperamide 2mg oral tablet for diarrhea prn administer per box label. It does not include specific instructions for frequency. (corrected on site) The RN visit note dated 9/28/22 indicates the patient has scrotal itching and the spouse is using an antifungal cream. This medication is not on the plan of care.

Upon patient record review, 3 of 13 (Patient #2, #6, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2-The RN documented on 10/17/22 that a blood sugar was obtained by the RN. There is no order for this treatment/intervention and it is not on the plan of care. The RN documented on 11/22/22 an attempt to place a foley catheter. There was no order for this intervention included in the plan of care. Patient #6-The plan of care dated 11/08/2022 states SW frequency of 1X/month and 2 prn. The MSW documented visits on 11/9/22 and 11/16/22. Neither visit was documented as prn. Patient #8-The RN visit note dated 10/31/22 indicates the the RN applied anti-itch cream with lidocaine. There was no order for this intervention included in the plan of care.

Upon patient record review, 2 of 13 (Patient #1, #2) did not have evidence that Social work services were provided timely based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #1-On 11/23/22 the nurse documents the patient requested a social worker visit for a power of attorney and the social worker was notified. The only documentation on record regarding the 11/23/22 POA request occurred on 11/28 at which time the social worker documented reaching out to the caregiver and making a referral for a mobile notary. The 11/28/22 documentation did not evidence offering a visit and the documentation on record does not evidence the social worker coordinated with other team members (Nurse and Chaplain). Patient #2-The RN indicated the patient may need an alternate caregiver. There was an order dated 10/14/22 for "SW evaluation at family request". The MSW did not complete the initial evaluation until 10/17/22 to address the family's request and identified needs.

Upon patient record review, 2 of 13 (Patient #1, #8) did not have evidence that all entries are complete. Patient #1- The nurse documented on 11/28/22 that MS ER and lorazepam were administered. Dose and route were not documented for either medication. (late entry clarification correction on site). Patient #8 -The RN visit note dated 10/31/22 indicates the the RN applied anti-itch cream with lidocaine. The RN visit note dated 11/4/22 indicates the RN applied cream. There is no documentation of the specific medications applied.

Upon patient record review, 2 of 13 (Patient #4, #5) did not have evidence that the discharge summary includes all required information. Patient #4, #5-Both patients were live discharges and the discharge summary only includes the reason for discharge. The discharge summary does not include: a summary of the patient's stay, including treatments, symptoms and pain management as well as ongoing needs that cannot be met.