Every finding on record at Accord Hospice and Palliative Care, Inc.

Upon patient record review, 2 of 15 (Patient #2, 13) 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 2: The medication list recorded, "Acetaminophen 500mg 2 tablets oral twice daily, Acetaminophen 1 tablet oral every six hours as needed, and Hydrocodone-Acetaminophen tablets 10-325mg oral 1 tablet every six hours as needed." There was no further documented evidence of maximum daily dose. Patient 13:The medication list recorded, "Glycolax Powder give 17 grams orally once daily." There is no further documented evidence of clarification of medication instructions to mix the powder with a diluent.

Upon patient record review, 3 of 15 (Patient #1, 2, 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 patient is followed by a wound care specialist who is performing sharp debridement and dressing applications with the use of Allograft. The wound care orders present on the 10/24/25 recertification plan of care are incomplete as they do not specify the responsible party to perform the wound care as ordered by the MD. Patient 2: The plan of care recorded, "Acetaminophen 500mg 2 tablets oral twice daily, Acetaminophen 1 tablet oral every six hours as needed, and Hydrocodone-Acetaminophen tablets 10-325mg oral 1 tablet every six hours as needed." There was no further documented evidence of maximum daily dose. Patient 13:The plan of care recorded, "Glycolax Powder give 17grams orally once daily." There is no further documented evidence of clarification of medication instructions to mix the powder with a diluent.

Upon client record review, 1 of 15 (Patient #1) 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 recertification plan of care order dated 10/24/25 records, "Skilled Nurse to change to change patient's suprapubic catheter once every 4 weeks or as needed if blocked or leaking." The catheter change should have been completed the week of 11/23/25 There is no documented evidenced found in the medical record of the catheter being changed at any skilled nursing visit through 11/28/25.

Upon personnel record review, 1 of 11 (Personnel # 2) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #2: The "Competency Skills Checklist Hospice Aide" dated 08/02/25 records the evaluation method for all tasks as verbal. There was no further documented evidence that the competency assessment was performed by the aide with a patient or pseudo-patient.

Upon patient record review, 1 of 15 (Patient #2) 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 2: The "Hospice Aide Care Plan" with a note date of 11/11/25 indicated the tasks change bed linens, make bed, and straighten room with a frequency of "as needed."

Upon personnel record review, 1 of 11 (Personnel # 1) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel 1: There was no evidence found of a completed job description for the role of Alternate Administrator.

Upon patient client record review, 1 of 15 (Patient #2) 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 2: The completed form located in the medical record titled, "Election of Medicare Hospice Benefit" did not address the election or declination of receipt of the, "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" as this section on page 2 was unaddressed, with both selections blank, lacking the required checkmark or "X" to show the form was elected or declined.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the IDG did not update the comprehensive assessment. For HV2 the IDG update 8/11 did not include documentation that aide services had been added 6/1 and Bisocodyl had been added for the patient's constipation. The IDG update 8/27 did not include documentation that the Metoprolol dose had been increased and thickened liquid with ice was ordered 8/12. And the 11/3 IDG update did not reflect that the aide was discontinued 10/27. This was verified by the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the organization did not have time frames for achieving goals on patient's care plan. The EMR did not did not allow the modification of the establishing goals with time frames. This was evident in the following records: HVs 1 and 2, RRs 1, 2, 3, 4, 5, 6, 7, 8, and 9. This was verified by the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the plan of care did not include all drugs and treatments necessary to meet the needs of the patient. In the record of RR3 the oxygen did not have liter flow, method of delivery and frequency of oxygen. In addition there was no specified treatment for the wound. For RR6 the patient developed a wound and the nurse stated wound care was done, however, the plan of care was not updated with wound care treatment until 7/28. This was confirmed with the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the aide did not communicate with the nurse regarding changes in the patient's care or condition. For example, in HV1 the patient requested showers instead of bed baths. The aide gave the patient showers and did not document that the nurse had been notified. In RR6 beginning 8/11the patient refused showers opting for bed bath for the majority of subsequent visits. There was no documentation that the aide had reported this change to the nurse. In addition, on 7/26 the aide documented the patient had a new skin tear. There was no documentation that this new problem was reported to the nurse. This was verified with the Alternate Administrator/DPCS.

Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was verified by the Alternate Administrator/Alternate DPCS. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was verified by the Alternate Administrator/Alternate DPCS. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. This was verified by the Alternate Administrator/Alternate DPCS. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was verified by the Alternate Administrator/Alternate DPCS. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was verified by the Alternate Administrator/Alternate DPCS.

Observed in Infection Control Tracer. In 11 of 11 patient records reviewed, the hospice social worker and spiritual counselor did not sign attendance at the IDG meetings as required by agency policy No. 2-050.1 which stated all IDG members would be in attendance and sign the attendance form. This was evident for all IDG meetings for the following records: HVs 1 and 2, RRs 1, 2, 3, 4, 5, 6, 7, 8, and 9. This was verified by the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 6 of 11 patient records reviewed, which had aide services there were no parameters for aide to report abnormal findings when taking patient vital signs. The records with aide services were HVs 1 and 2, RRs 6, 7, 8, and 9. This was verified with the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the aide did not follow the patient's care plan. For example, in HV2 on 8/1 the patient was to be given a bed bath. The aide gave the patient a shower on 8/4, 8/18, 9/8 9/22, and 9/29. On 9/11 the aide only completed the vital signs and did not explain why rest of care plan was not followed. This was verified by the Alternate Administrator/DPCS.

Observed in HR File Review. In 5 of 8 HR files reviewed, HIPAA re-training was not done periodically at an interval required by policy.  The policy on Privacy Training 1-022.1 did not address re-training, only training at orientation. All staff, except the volunteer coordinator, volunteers, and social work had not had retraining. In addition, the spiritual counselor/bereavement counselor had not had OSHA blood-borne pathogen education for 2021 and 2022. There was no in-service planned for the remainder of the year. This was verified by the Alternate Administrator/DPCS. Observed in HR File Review. The Bereavement Counselor did not have a competency assessment on hire. This was verified by the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 5 of 11 patient records reviewed, the organization did not provide the attending physician with a copy of the discharge summary. The physician was notified of the discharge, however, no summary was provided. This was evident in the following records: RR1, RR2, RR3, RR4, and RR6. This was verified with the Alternate Administrator/DPCS.

Observed in Individual Tracer. In 5 of 11 patient records reviewed, the organization did not document a discharge summary which included a summary of the patient's stay. This was evident in the following records: RR1, RR3, RR3, RR4, and RR5. This was verified by the Alternate Administrator/DPCS.