Every finding on record at Alamo Area Home Hospice, LP

Upon patient record review, 4 of 19 (Patient #2, #3,#15,#17) 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: On home visit medication reconciliation found patient in SNF to be taking Metamucil 1 TBS PO QD, no evidence med on hospice medication profile. Patient #3: On home visit medication reconciliation found patient in SNF to be taking Acetaminophen supp. 650mg one PR PRN pain or fever. No evidence of this med on hospice medication profile. Patient #15: Medication profile dated 6/10/2024 with O2 at 2-5L via NC continuous. No evidence of parameters. Patient #17: SOC identifies pt. using 7.5L of O2. Co-morbidity diagnosis of O2 Dependent. No evidence of O2 on the medication profile. Medication profile dated 4/11/2024 with Miralax 17Gm powder daily PO, no evidence of a diluent.

Upon patient record review, 2 of 19 (Patient #7,#15) 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 #7: Identified at SOC no funeral planning. No funeral planning on POC. Corrected on site. Patient #15: SOC patient on Eliquis, no evidence on POC for bleeding risk/precautions.

Upon patient record review, 4 of 19 (Patient #2,#3,#15,#17) 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 #2: On home visit medication reconciliation found patient in SNF to be taking Metamucil 1 TBS PO QD, no evidence of an order for this med. Patient #3: On home visit medication reconciliation found patient in SNF to be taking Acetaminophen supp. 650mg one PR PRN pain or fever. No evidence of an order for this med. Patient #15: Order dated 6/10/2024 O2 2-5L via NC continuous. No evidence of parameters. Patient #17: SOC identifies pt. using 7.5L of O2. Co-morbidity diagnosis of O2 Dependent. No order on POC for O2. Order dated 4/11/2024 Miralax 17Gm powder daily PO, no evidence of a diluent.

Upon patient record review, 1 of 19 (Patient #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 #12: 12/23/2024 order to dc two medications related to worsening dysphagia. No evidence on POC for dysphagia/risk of aspiration. Corrected on site.

Upon patient record review, 5 of 19 (Patient #7,#8,#12,#16,#18) 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 #7: SN identified fall risk, no evidence of fall risk on Aide assignment. Corrected on site. Patient #8: SN identified dysphagia at risk for aspiration. No evidence of aspiration risk on aide assignment. Corrected on site. Patient #12: SN identified worsening dysphagia on 12/23/2024. No evidence on aide assignment of risk for aspiration. Corrected on site. Patient #16: SN identified dysphagia/risk for aspiration. No evidence on aide assignment for aspiration precautions. Patient #18: SN identified fall and seizure risks. No evidence on aide assignment of fall and/or seizure precautions.

Upon patient record review 2 of 19 (Patient #5, #8) 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 #5: Aide frequency order dated 12/31/2024- 2x week. Week of 1/19/2025 one visit made with no evidence of a missed visit. Patient #8: Aide frequency order dated 1/3/2025- 3x week. Week of 1/19/2025 two visits made with no evidence of a missed visit.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. 2024 end of year for parent Boerne office 4.6%, Kerrville office (branch) 4.1%.

Upon patient record review, 1 of 19 (Patient #19) 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 #19: Order dated 6/22/2024 "may LOTA abrasion to right forehead. Monitor and report any signs of infection". Per Executive Director is abbreviated "may leave open to air" Not an approved abbreviation. No evidence of of a clear entry.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #16: Revoked to go to higher level of care- hospitalized. No evidence of transfer summary sent to facility.

Upon patient record review, 4 of 19 (Patient #1,#2,#3,#4) 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: Last POC dated 12/26/2024, no evidence of names and contact information for hospice personnel involved in hospice care of patient. Patient #2: Last POC dated 1/22/2025, no evidence of names and contact information for hospice personnel involved in hospice care of patient. Patient #3: Last POC dated 12/26/2024, no evidence of names and contact information for hospice personnel involved in hospice care of patient. Patient #4: Last POC dated 1/22/2025, no evidence of names and contact information for hospice personnel involved in hospice care of patient.

Upon patient record review, 2 of 13 (Patient #1 and 12) 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 Patient #1: Miralax powder on medication profile without evidence of instructions for diluent transcribed to the medication profile. Patient #12: The RN narrative 2-21-22 documented oxygen as needed for dyspnea, however, oxygen was not included on the medication profile.

Upon patient record review, 1 of 13 (Patient #12) 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 #12: The RN narrative 2-21-22 documented oxygen as needed for dyspnea, however, there was no evidence of an order for oxygen.

Upon client record review, 1 of 13 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: Wound care was provided on 2-23-22 without evidence of wound care orders being part of the plan of care.

Upon patient client record review, 3 of 13 (Patient #4, #7, #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 #4: RN documented a supervisory visit for the aide on 11-22-21. There was no evidence of an aide visit until 11-24-21. Patient #7: RN documented a supervisory visit for the aide, but there was no evidence of an aide visit during the patient's hospice stay. Patient #12: RN Narrative dated 2-1-22 documented "GNP increased to 1000mg TID". No indication what was increased and no evidence of medication of 1000mg on medication profile.

Upon client record review, 1 of 5 applicable patients (Patient #13) 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 #13: MSW visit ordered monthly. No evidence of MSW visit or missed visit documentation in February 2022.