Every finding on record at Advanced Hospice Care LLC

Upon client record review, 1 of 5 (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: On the SN visit dated 1/13/26 there is documentation, “O2 @ 4lpm continuously. Instruct patient on pulmonary hygiene, coughing, deep breathing, O2 use and safety, nebulizer pre physician orders", there are no orders for oxygen or medications for a nebulizer on the plan of care. Corrected on site.

Upon patient record review, 5 of 5 (Patients #1,#2,#3,#4,#5) 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: The medication record contained an order for oxygen with no delivery method, methylprednisone with no dose and frequency, albuterol inhaler with no dose and spacing between PRN doses, nystatin topical with no area defined for administration, and polyethylene glycol with no instructions to mix with a diluent. Patient 2: The medication record contained orders for polyethylene glycol with no instructions to mix with a diluent, and menthol-zinc oxide topical cream with no area defined for administration. Patient 3: The medication record contained orders for guaifenesin PRN and Senna-S PRN with no spacing between PRN doses, and oxygen with no delivery method. Patient 4: The medication record contained orders for midodrine PRN with no spacing between PRN doses, and oxygen with no delivery methods. Patient 5: The medication record contained orders for nystatin topical cream with no area defined for administration, Novolog with no dose, and oxygen with no delivery method.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 5 (Patient #3) 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 3: The plan of care contained two conflicting RN frequency orders for once weekly and twice weekly the week of 10/23/25.

Upon patient record review, 5 of 5 (Patients #1,#2,#3,#4,#5) 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 an order for oxygen with no delivery method, methylprednisone with no dose and frequency, albuterol inhaler with no dose and spacing between PRN doses, nystatin topical with no area defined for administration, and polyethylene glycol with no instructions to mix with a diluent. The record also contained nursing documentation upon admission identifying patient use of a bi-pap. There was no evidence of an order for bi-pap parameters. Patient 2: The medical record contained orders for polyethylene glycol with no instructions to mix with a diluent, and menthol-zinc oxide topical cream with no area defined for administration. The record also contained nursing documentation upon admission identifying patient has a suprapubic catheter. There was no evidence of an order to include suprapubic catheter type, size, and maintenance. Patient 3: The medical record contained orders for guaifenesin PRN and Senna-S PRN with no spacing between PRN doses, and oxygen with no delivery method. The record also contained nursing documentation upon admission identifying patient use of a bi-pap. There was no evidence of an order for bi-pap parameters. The record contained a wound care order with no instructions for cleansing or scheduled frequency to change border dressing. Patient 4: The medical record contained orders for midodrine PRN with no spacing between PRN doses, and oxygen with no delivery methods. Patient 5: The medical record contained orders for nystatin topical cream with no area defined for administration, Novolog with no dose, and oxygen with no delivery method.

Upon client record review, 1 of 5 (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 medical record contained an order for spiritual care visits once weekly effective 11/3/25. There was no evidence of a visit completed the week of 11/9/25.

Upon patient record review 2 of 5 (Patients #1,#3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 1,3: The plan of care outlines spiritual needs with goals and interventions to collaborate and identify a spiritual leader and patient to feel more connected to community. There was no evidence the agency referred the patient to the chaplain or made connections with a community leader.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 2: The aide has no emergency preparedness training and has been seeing patients since 7/16/25.

Upon patient record review, 1 of 5 (Patient #1) 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: Patient 1: The medication profile contains Triamcinolone Acetonide 0.1% External 1 twice daily as needed for dry skin. It does not include a site. Corrected on site, med profile updated.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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 1,2,3,4,5: The bereavement assessments only documented that patient's bereaved were not at risk for difficult bereavement, there was not evidence of comprehensive assessment which included 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.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient 4: The medical record does not contain a plan of care that is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions.

Upon patient record review, 2 of 5 (Patient #2,5) 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: Per POC pt is taking ASA daily and is a fall risk. There is no risk for bleeding with goals and interventions initiated. Corrected on site care plan updated. Patient 5: Pt is on Apixaban (Eliquis) daily, there is no risk for bleeding care plan initiated with goals and interventions.

Upon patient record review, 4 of 5 (Patient #1,2,3,5) 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: Patient 1: The POC contains evidence that the patient is in their fourth benefit period. The visit orders for RN, MSW, SCC and HHA are all written for 3 months. This should be a 60 day certification period. Patient 2: The POC 8/2/25 contains an order for MSW 1 time a month starting 8/4/25 and end date 8/3/25. RN/LVN 1 time per week for 13 weeks starting 8/4/25 end date 8/3/25. Patient 3: The POC 8/16/25 contains an order for SN 1 time a week starting 8/16/25 for 8 weeks and end date 8/17/25. There are no SN visit orders from SOC until IDG where there is an order for SN visits starting 9/23/25 1 time a week for 8 weeks. Patient 5: The POC contains an order for MSW 1 time per month for 3 months starting 9/27/25 and ends 9/26/25.

Upon patient record review, 2 of 5 (Patient #1,4) 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 POC contains Triamcinolone Acetonide 0.1% external, 1 twice daily as needed for dry skin. It does not include a site. Corrected on site, order updated. Patient 4: The medical record contains an physician interim order on 9/2/25 for Jevity 1.5ml/hour x 16 hours to provide 1200ml/1800calories/76 G protein/912 free water flush at 62ml/hr x 16 hours. It does not state who will provide this feeding.

Upon client record review, 3 of 5 (Patient # 2,3,4) 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 POC contains an for SN 2 times per week 9/3/25 week 1. The SN only made 1 visit that week. Patient 3: The SN performed visits on 8/19, 8/27, 8/29, 9/2, 9/16/25 with out an order. Patient 4: The SN performed visits the following dates with no orders to visit: 8/18, 8/19 ,8/20, 8/21, 8/22, 8/23/25. The SN provided Peg tube care at each of these visits with no orders. SN applied heal protectors with no order on 8/20/25. SN provided wound care to Right heel with no orders on 8/22/25.

Upon patient record review 2 of 5 (Patient #1,4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 1: The comprehensive assessment contains documentation by the RN of performing the SC assessment and then "pt open to SC support referral." This has not been completed. Patient 4: The MSW made a visit on 8/19/25 for comprehensive assessment. The SN comprehensive assessment has documentation by the RN that pt had an unsafe discharge from the SNF and the SNF had already called APS. The MSW documented pt is cared for by a significant other that was recently appointed DPOA, has a poor support system, does not have adequate coping mechanisms and is not forthcoming with information. The MSW also documents that the caregiver is capable of providing care. There were no further follow up visits made by the MSW and no further referrals made by the SN for MSW needs. The SN documented pt being found in wet bed sheets each visit, having pulse ox in the 60-70 range and not using O2, difficulty for caregiver to provide care due to pt being large in size and being much taller that caregiver and uses a Hoyer lift with 2 person assist, caregiver not giving medications as ordered, giving patient PO water when pt is NPO and high aspiration risk. The MSW was informed of the above on 8/22/25 and called APS to discuss the issues the hospice is having with the caregiver and pt. APS informed them the "patient had only been home for a week and they need to give the caregiver time to prove herself." There is no evidence of respite being offered or increase of SN visits being offered to further assist this pt and caregiver to be successful in their care.

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 2: The SN documented 10/1/25 and 10/9/25 pt is having several falls and there has not been any incident reports filed.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel 2: There aide did not have evidence the the employee file that they had the following: A training program and competency evaluation as specified in CFR 418.76(b) and 418.76(c) , A competency evaluation program that meets the requirements of CFR 418.76(c), A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 and is currently listed in good standing on the state nurse aide registry, A state licensure program. Agency pulled the aides credentials while surveyor present but there was no evidence this was done upon hire.

Upon personnel record review, 1 of 2 (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 aide had no competency in her employee file and has been seeing patients since July 16, 2025.

Upon patient record review, 3 of 5 (Patient #1,2,3) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The aide POC 9/3/25 contains a directive by the RN to shampoo hair "per pt request". There is documentation that pt is forgetful and unable to provide her own care on comprehensive assessment. There is no documentation stating pt is cognitively able to make their own decisions. Patient 2: The aide POC 8/2/25 contains a directive by the RN to shampoo hair "per pt request". There is documentation that pt is forgetful and there is no documentation stating pt is cognitively able to make their own decisions. Patient 3: The aide POC 8/16/25 contains a directive by the RN to shave patient per patient request. The SN documented on the aide POC pt is confused and forgetful. There is no documentation stating pt is cognitively able to make their own decisions.

Upon patient record review 4 of 5 (Patient #1,2,3,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The aide POC 9/3/25 contains an order for aide starting 9/3/25 1 time a week for 1 week and starting 9/7/25 for 2 times a week for 11 weeks. There has only been 1 aide visit completed on 10/6/25. There is no missed visit documentation or order to discontinue aides. Patient 2: The aide POC and IDG notes all contain orders for the aide to see pt twice weekly starting 8/10/25. The aide did not see patient twice weekly the weeks of 9/7 and 9/14. The last visit made by the aide was 9/15/25 and there is a discontinue order for aides on 9/27/25 there were no visits by the aide the week of 9/21-9/27. There is no missed visit documentation or evidence of refusal of visits. Patient 3: The POC 8/16/25 contains an order for aides to start on 8/18/25 for twice weekly visits. The aide has not seen the patient and there were no missed visits documented or evidence of refusals of visits. There was no discharge order written until 8/27/25. Patient 4: The aide made a visit on 8/20 and 8/22 with no aide visit orders.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence that Hospice Homemaker Services are provided by qualified personnel in accordance with the state's occupational certification regulations, where applicable, federal regulations and the hospice's policies and procedures and/or job descriptions. Personnel 2: The aide credentials were not assessed until 10/13/25 during survey.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 2: did not have evidence of receiving orientation on the hospice philosophy.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 2: did not have evidence that the employee had received orientation on their specific job requirements.

Upon patient client record review, 1 of 5 (Patient #5) 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 5: The election statement does not include the opportunity for the patient or caregiver to elect to obtain a copy of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs.

Upon patient client record review, 1 of 5 (Patient #1) 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: The RN performed a supervisory visit on 10/09/25 it does not state who was supervised.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient 4: The medical record did not contains the latest physician orders including a discharge order.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 2: The agency did not check the aides credentials prior to hiring.

Upon personnel record review, 2 of 2 (Personnel #1,2) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 1 and 2: The State of MI per Michigan state Act 28 of 2006; MI Choice Waiver Minimum Operating Standards requires they perform a background check in the state of MI and Federal background check before they begin working upon hire, agency used "LARA" criminal background checks which is for the State of MI, they did not perform a federal background check that includes where the personnel lived or worked the past 3 years.

Upon patient record review, 1 of 5 (Patient #4) 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 #4: Nystatin was ordered on 02/14/25 with no indication for use or where it was being applied listed on the medication profile.

Upon patient record review, 1 of 5 (Patient #5) 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 #5: MSW was ordered for 1 visit every 6 weeks. the last visit was made on 01/23/25, making the next visit due by 03/05/25. On 02/13/25, an order was written by another MSW, for prn only visits which is an unacceptable frequency. The order was corrected on site and the patient was to have a visit 03/18/25.

Upon patient record review, 1 of 5 (Patient #4) 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 #4: POC orders written for Nystatin on 02/14/25 with no indication for use or where it was being applied.

Upon patient record review, 1 of 5 (Patient #4) 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 #4: There was DME listed on the plan of care, however, supplies, including briefs, gloves, wipes and incontinent supplies were not on the plan of care. In addition, on 03/02/25, there was an order for a knee mobilizer, however, it was noted why this was needed and it was not added to the plan of care.

Upon patient record review, 1 of 5 (Patient #4) 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 #4: The patient was admitted 2/5/25 to hospice on Augmentin, reportedly for a UTI. There was no discussion of infection in the plan of care except under safety. On 02/19/25 another Urinalysis was ordered and Bactrim DS was ordered bid for 5 days. There was no change or update to the plan of care. On 03/11/25, after another urinalysis, Macrobid was ordered daily for 7 days with no change or update to the plan of care.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #7, #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: The record indicated the patient elected the hospice benefit on 08/05/24. There was no evidence the patient chose an attending physician. This was blank on the legal document. Patient #7: The record indicated the patient chose an attending for it to be the hospice medical director. She verbalized during a home visit she did not get a choice that "the hospice chose for me." COS. Patient #10: The record indicated the start of care was on 10/01/24. There was no evidence the patient chose an attending physician. This was blank on the legal document.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 3 of 14 records reviewed (Patient #4, #9, #10) 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. Patients #4: The start of care for hospice was on 03/16/23. There was no evidence of the spiritual comprehensive assessment being completed until 03/29/23. Patient #9: The start of care for hospice was on 09/18/24. There was no evidence of the psychosocial comprehensive assessment being completed until 09/30/24, additionally it was not fully completed as there was no financial and or environmental assessment completed at the time of the survey. Patient #10: The start of care for hospice was on 10/01/24. There was no evidence of the psychosocial comprehensive assessment being completed until 10/10/24.

Upon patient record review 7 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #7, #8) 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: The record indicated the patients start of care for hospice was on 08/05/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #2: The record indicated the patients start of care for hospice was on 02/28/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #3: The record indicated the patients start of care for hospice was on 10/29/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #4: The record indicated the patients start of care for hospice was on 03/16/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #5: The record indicated the patients start of care for hospice was on 09/21/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #7: The record indicated the patients start of care for hospice was on 07/26/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #8: The record indicated the patients start of care for hospice was on 10/25/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey.

Upon patient record review, 5 of 14 records reviewed (Patient #2, #6, #7, #8, #9) 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: During home visit, noted the patient had a prescription that was filled on 11/18/24 for Nystatin 100,000U per gram apply to affected area "both thighs" BID. There was no evidence this was on the medication profile at the time of the home visit and the prescription was written by the Hospice Medical Director. The family verbalized the patient is currently using this medication. COS. Patient #6: The record indicated the patients start of care was on 03/14/24. The record indicated a review on 03/22/24 when Ativan 0.5mg po Q8hours was ordered. The medication profile had multiple medications listed at the start of care. There was no review completed at the start of care for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy, and or drug therapy currently associated with laboratory monitoring. Patient #7: The medication profile indicated oxygen inhalation 4 LPM supplemental for shortness of breath. There was no evidence of the route for administration. COS. Patient #8: The record indicated the medication profile had 19 medication listed at the start of care on 10/25/24. Loperamide 2mg one tab prn needed for antidiarrhea, max 4 tab in 24 hours was ordered on 12/20/24, there was no review to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and or drug therapy currently associated with laboratory monitoring at the time of the survey. Patient #9: The record indicated the medication profile has Tylenol 500mg 2 tabs pro four time a day prn pain ordered on 09/18/24 and Acetaminophen ES 500mg one tab TID on 10/03/24. There was no evidence to NTE 4gm in a 24 hour period. COS.

Upon patient record review, 1 of 14 records reviewed (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: The start of care for hospice was on 03/16/24. There was no evidence of a bereavement risk assessment until 03/29/23.

Upon patient record review, 1 of 14 records reviewed (Patient #6) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #6: The patient chose their attending physician at the start of care on 03/14/24. There was no evidence in the written plan of care that the plan developed by the IDG consulted the patient's attending physician at the time of the survey.

Upon patient record review, 5 of 14 charts reviewed (Patient #1, #5, #6, #7, #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 #1: The record indicated 08/05/24 at the start of care that the patient had a stage 2 ulcer in the care plan. There was no evidence in the individualized care plan for the wound care, there was no location of the wound documented. COS. Patient #5: The record indicated on 09/21/24 during the initial comprehensive assessment the patient was a full code and had no funeral arrangements. There was no evidence of an individualized written plan of care addressing these problems identified in the initial comprehensive assessment at the time of the survey. COS. Patient #6: The record indicated on 03/14/24 at the start of care the patient was a full code. There was no evidence in an individualized written plan of care addressing this problem identified in the initial, comprehensive assessment. COS. Patient #7: The record indicated on 07/26/24 at the start of care the patient had no funeral arrangements. There was no evidence in an individualized written plan of care addressing this problem identified in the initial, comprehensive assessment. COS. Patient #10: The record indicated the patient was on insulin Levemir 100U/ml 14U SQ BID long acting and 10U SQ BID short acting. There was no individualized written plan of care addressing taking blood sugar levels and what to report regarding hypoglycemia and or hyperglycemia. In addition, there is an MD order written on 01/17/24 to cleanse all wounds with wound cleanser, pat dry with gauze. Paint necrotic area of wounds to left heel and right upper ankle with betadine, cover with Telfa, secure with gauze and tape. Apply pink dressings to all wounds 3 X weekly and prn for saturation or dislocation of dressing. Wear pressure relieving boots while in chair and in bed. There was no evidence of an individualized written plan of care for this wound care. Both COS.

Upon patient record review, 2 of 14 records reviewed (Patient #7, #9) 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. Patients #7: The record indicated an MD order was written for oxygen inhalation 4 LPM supplemental for shortness of breath. There was no evidence of the route for administration. COS. Patient #9: The record indicated an MD order on 09/18/24 for Tylenol 500mg 2 tabs po four time a day prn pain and an order on 10/03/24 for Acetaminophen ES 500mg one tab TID. There was no evidence in the order NTE 4gm in a 24 hour period. COS.

Upon patient record review, 4 of 14 charts reviewed (Patient #1, #2, #3, #4) 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: The record indicated the patient was receiving medical supplies. The plan of care did not list out the following items briefs, medium gloves and wipes. COS. Patient #2: The record indicated the patient was receiving briefs. The plan of care did not have this item listed. COS. Patient #3: The record indicated the patient was receiving briefs. The plan of care did not have this item listed. COS. Patient #4: The record indicated the patient was receiving wipes. The plan of care did not have this item listed. COS.

Upon client record review, 3 of 14 records reviewed (Patient #5, #8, #10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #5: The record indicated there was an IDG meeting on 11/01/24 and then the next meeting was 17 days later on 11/18/24. There was no evidence between these IDG dates of the meeting taking place less than every 15 calendar days. Patient #8: The record indicated the IDG on 11/01/24 did not have a Social Worker Signature to show IDG attendance. The record indicated the IDG on 12/13/24 did not have a Social Worker Signature to show IDG attendance. The record indicated the IDG on 01/10/25 did not have a nurse, social worker or chaplain signature to show attendance. all COS. Patient #10: The record indicated the IDG on 11/01/24 IDG did not have a nurse, social worker and or chaplain signature to show attendance. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #5) 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 #5: The record indicated the patients start of care was on 09/21/24. There was a documented skin tear on the left lower extremity on 09/24/24. There was no revised plan of care based off this updated comprehensive assessment, and no notations of the progress towards outcomes and or goals in the plan of care.

Upon client record review, 2 of 14 charts reviewed (Patient #2, #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients #2: The record indicated an order for the chaplain to go 2 X M X 3M to start on 12/24/24. The next visit was on 01/09/25 and no visits made on or after the order date of 12/24/24. Patient #6: The record indicated nurse visits were made on 5/24/24, 05/30/24, 06/05/24 and 06/11/24. There was no frequency orders for these nurse visits in the record at the time of the survey.

Upon patient record review 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #9: The record indicated the psychosocial comprehensive assessment was completed on 9/30/24. The Social Worker documented a present pain level of "8" with a "2" being an acceptable pain level. There was no notification to the nurse of this uncontrolled pain.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: The hospice aide placed her bag on a barrier on the floor. Policy PC.120 Bag Technique #1 states select and prepare adequate work space from which to use the bag. Since floors are considered to be highly contaminated bags are never to be placed on the floor. Patient #7: The hospice nurse used the patients tissue with hand sanitizer to clean a flat surface for the BP Cuff and then to cleanse the cuff. Policy PC.120 #10 states all equipment is cleansed with disinfectant after use and before returning to the bag.

Upon patient record review, 1 of 14 records reviewed (Patient #8) 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 #8: The Hospice Aide care plan was not written until 11/06/24 at 2:36 p.m. by the RN. The hospice aide provided hands on care prior to the development of the hospice aid plan of care.

Upon patient record review 2 of 14 charts reviewed (Patient #9, #14) 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 training Patient #9: The IDG ordered the aide frequency to be "HA 2 X W X 13 W" on 12/20/24. The aide made a visit on 12/20/24 and on 12/27/24. Patient #14: The record indicated by the nurses documentation the hospice aide provided post mortem care. There was no evidence of an order for the hospice aide visit and or there was no visit note from the hospice aide regarding the care provided.

Upon patient record review 1 of 14 charts reviewed (Patient #8) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #8: The records indicated the Hospice Aide documented a pain level of 7/10 on 11/06/24 at 8:34 a.m. - 9:30 a.m. There was no report given to the RN by the Hospice Aide.

Upon patient record review 1 of 14 records reviewed (Patient #9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #9: The record indicated a supervisory visit was made on 12/24/24, 12/31/24 and 01/07/24. There was no evidence of which discipline this supervisory was completed in the field for the discipline name, it was left blank on all three supervisory visits.

Upon patient client record review, 3 of 14 charts reviewed (Patient #1, #7, #10) 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 record indicated the patient elected the hospice benefit on 08/05/24. There was no evidence the patient chose an attending physician. This was blank on the legal document. Patient #7: The record indicated the patient chose an attending for it to be the hospice medical director. She verbalized during a home visit she did not get a choice that "the hospice chose for me." COS. Patient #10: The record indicated the start of care was on 10/01/24. There was no evidence the patient chose an attending physician. This was blank on the legal document.

Upon patient client record review, 1 of 14 records reviewed (Patient #10) did not evidence that each patient record contains physician orders. Patient #10: The record indicated the patient was discharged on 12/12/24. There was no evidence in the record at the time of the survey for a discharge order.

Upon patient record review, 1 of 14 records reviewed (Patient #1) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #1: The record indicated the patient is residing in a SNF. There was no evidence of the CTI on the patients chart at the time of the in person surveyor visit. COS.

Upon patient record review 1 of 5 (Patient #1) 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: There was no evidence of a spiritual assessment being completed.

Upon patient record review, 1 of 5 (Patient #2) 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 #2: Per nursing note dated 2/22/22, Bactrim DS was discontinued. Bactrim DS was not documented as discontinued on the medication profile. Additionally, the medication profile did not indicate route of administration for all 6 medications listed on the medication profile. Corrected on site.

Upon patient record review, 2 of 5 (Patient #4, #5) 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. Patient #4 and #5: Both patients desired full code and there were no interventions or goals related to code status.

Upon patient record review 1 of 5 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #2: The aide plan of care indicated "Assist Bath- Chair". On 1/21/22 and 2/4/22, the aide did not document completion or refusal of order to Assist Bath-Chair