Every finding on record at Alexius Hospice Care Inc

Upon patient record review, 1 of 10 (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. 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\Oxygen not on medication list Patient #2 - Oxygen not on medication list but patient is on O2 at 2L/M nasal cannula PRN.

Upon patient record review, 1 of 10 (Patient #6) 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 #6 - IDG held on 07/16/24 then again on 08/05/24 which is greater than 15 days.

Upon patient record review, 3 of 10 (Patient #1, 2, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 2, 3 - SC visit frequency 1 x month. No SC visit made the month of November and no missed visit documentation.

Upon patient record review 2 of 10 (Patient #3, 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 training Patient #3 - During home visit aide provided bed bath instead of shower, shower is the only bathing task on care plan. Patient #6 - Aide visit frequency 2xwk only 1 visit week of 07/14/25 and 0 visits week of 07/21/25, there was no missed visits documented.

Upon patient record review 2 of 10 (Patient #2, 6) 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 #2 - Aide supervisory visit 11/03/25 then 11/18/25 (15 days between supervisory visits). Patient #6 - Aide first visit on 07/16/25 supervisory visit documented on 08/01/25 but should have been completed on 07/30/25.

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not contain evidence that an Aide Skills Competency Assessment had been conducted, which included all CMS-required content. The skills competency dated 6/10/21 did not include: The physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice.

Upon patient record review, 1 of 6 (Patient #1) did not contain evidence that each patient record contained: A signed Election of Hospice Benefit Statement, in accordance with 418.24. The Election Statement form was blank where the patient was to have designated his/her Attending Physician of choice.

Upon patient record review, 5 of 6 (Patients #2, 3, 4 5, and 6) did not contain evidence that all entries were legible, clear, complete, and/or appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patients #3 and 4: All of the Aide-documented home visit notes contained the Aide's signature, without the addition of the Aide's credentials. Patients #2, 3, 4, 5, and 6: The admitting RN(s) had documented within the Initial SOC Assessment(s) that each of these patients had a DPOA-Healthcare, to include the documented name and contact information for legal surrogates. The Physician-signed POLST, dated the same date as each of these patients' Initial Assessments, did not include the designation of a DPOA-Healthcare. The Hospice Plan(s) of Care, dated same, did not reflect the presence of a DPOA-Healthcare. This is not clear documentation of these patients' Advance Directive status, or the absence of .

Upon contract review, 1 of 1 applicable (CC) did not contain a provision that the inpatient facility shall: Provide the Hospice with a copy of the Discharge Summary at the time of the patient's discharge from the inpatient facility.