Every finding on record at Aaa2 Healthcare LLC

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient 1: Upon home visit, the aide is wearing a name badge provided by the VA instead of agency name badge.

Upon patient record review 7 of 19 (Patient #1,2,4,6,7,8,9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1, 2, 4, 6, 8: There is no evidence of psychosocial and spiritual care comprehensive assessments being completed at SOC. Patient #7, 9: There is no evidence of spiritual care comprehensive assessments being completed.

Upon patient record review, 1 of 19 (Patient #3) 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 3: The agency medication profile does not have evidence of Acetaminophen, Dulcolax and Milk of Magnesia that are present on the medication profile at the SNF.

Upon patient record review, 7 of 19 (Patient # 1, 2, 4, 5, 8, 9, 13) 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 1, 2, 4, 5, 8, 9 and 13: There is no evidence of an initial bereavement assessment completion within 5 days of SOC.

Upon patient record review, 1 of 19 (Patient #10) 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 10: The POC on 3/12/26 contains an order for Eliquis. There is no evidence of risk for bleeding noted on the POC.

Upon patient record review, 1 of 19 (Patient #3) 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: The agency POC on 3/12/26 does not have evidence of Acetaminophen, Dulcolax and Milk of Magnesia that are present on the medication profile at the SNF.

Upon client record review, 1 of 19 (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: The POC on 1/21/25 contains an order for wound care to coccyx with saline cleanse, pat dry, apply calmoseptine, leave open to air with no frequency for wound care and who will provide care at SNF.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: There is no evidence of frequency of tasks assigned in Aide care plan on 2/25/26. Aide is given task for patient to be bedbound or chair to bed transfers with no frequency.

Upon patient record review 3 of 19 (Patient #4,5,6) 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 Patient 4: Aide tasks not documented on 2/26/26 as completed include hair care, mouth care, skin care, deodorant, application of lotion and pericare to be completed every visit. Patient 5: The aide documentation on 2/18/26 and 2/24/26 includes tasks not documented as completed including shower chair, hair care, mouth care, skin care, dressing, catheter care, pericare ordered to be completed every visit. Patient 6: Aide documentation on 2/20/26 includes tasks not documented as completed including change briefs, safety, hair care, mouth care skin care, dressing, catheter care and pericare ordered to be completed every visit.

Upon patient client record review, 8 of 19 (Patient # 1, 2, 3, 4, 5, 6, 7, 10, 12) 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 1: There is evidence of completion of SN visit notes 3/4 and 3/12/26 and multiple Aide visits 3/2-3/16/26 with no signature or date. Patient 2: There is evidence of SN visit notes completed on 3/05/26 with no signature or date by LPN. Patient 3: There is evidence of Aide visit notes completed on 3/05 and 3/2/26 with no signature or date. Patient 4: There is evidence of Aide visit notes on 3/2, 3/5, 3/9, 3/12 and 3/16/26 that are not signed and dated. The aide documents unacceptable abbreviations "gav bd bath" in documentation on 02/26/26. Patient 5: There is evidence of Aide visit notes on 3/3 and 3/10/26 that are not signed or dated. Patient 6: There is evidence of Aide visit notes on 3/5, 3/6, 3/9 and 3/12/26 are not signed or dated. Patient 7: There is evidence of Aide visit notes on 3/2, 3/6, 3/9 and 3/13/26 that are not signed or dated and SN visit completed on 1/4/26 not signed or dated. Patient 10: There is evidence of a LPN visit note on 1/10/26 not signed or dated and an RN visit note on 1/12/26 not signed and dated. Patient 12: There is evidence of multiple Aide visits completed between 2/4/26-3/16/26 not signed and dated.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 5: The POC on 1/21/25 contains an order for wound care to coccyx with saline cleanse, pat dry, apply calmoseptine, leave open to air with no frequency for wound care.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 5: The POC on 1/21/25 contains an order for wound care to coccyx with saline cleanse, pat dry, apply calmoseptine, leave open to air with no documentation of who will provide care at SNF.

Upon patient record review, 1 of 11 (Patient #4) 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 4: There is no evidence of an initial bereavement risk assessment within 5 days of hospice admission, or at any subsequent time since.

Upon patient record review, 2 of 11 (Patient #3, 8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: There was no evidence that a registered nurse saw the patient every 15 days to perform a comprehensive assessment and update the plan of care toward goals and outcomes. The RN saw the patient on 02.13.2023, then not again until 03.12.2023. Of note, the patient was seen by the LVN intermittently on 02.20.2023, 02.27.2023, and 03.06.2023, as required by SN visit orders. Patient 8: There was no evidence that a registered nurse saw the patient every 15 days to perform a comprehensive assessment and update the plan of care toward goals and outcomes. The RN saw the patient on 02.12.2023, then not again until 03.10.2023. Of note, the patient was seen by the LVN intermittently on 02.20.2023, 03.01.2023, and 03.08.2023, as required by SN visit orders.

Upon patient record review, 10 of 11 (Patient #1, 2, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence in the patient record that hospice aide assignments and duties are: • 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, 2, 4, 5, 6, 7, 8, 9, 10, 11: The hospice aide care plans did not indicate the frequency of the personal care tasks to be performed. (corrected onsite for all active patients)