Every finding on record at Alive Hospice Care, Inc.

Upon patient record review, 5 of 14 (Patient #1, #2, #5, #7, #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 #1: The medication list said "Oxygen 2-4 L inhalation as needed for shortness of breath which was is not an appropriate mode of delivery. Calmoseptine was in a treatment order but was missing from the med list. Upon review of the medication list the Lidocaine 4%/menthol 1% 1 unit topical every 12 hours prn pain was missing an application location. Lidocaine was corrected on site. Patient #2: There were treatment orders for Calmoseptine, Fleets Enema, Dulcolax Suppository and oxygen but the medications were not on the medication list. Patient #5: There was a treatment order for Calmoseptine but the medication was not on the medication list. Corrected onsite. Patient #7: There was a treatment order for oxygen but oxygen was not on the medication list. Patient #9: There was a treatment order for oxygen but the oxygen was not on the medication list.

Upon patient record review, 2 of 14 (Patient #3, #9) 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 #3: RN initial assessment the Braden score indicated the patient was a high risk for skin issues however, there was no evidence of a skin integrity problem with goals and interventions on the care plan. Corrected on site. Patient #9: RN initial assessment the Braden score indicted the patient was a high risk for skin issues however, there was no evidence of a skin integrity problem with goals and interventions on the care plan.

Upon patient record review, 7 of 14 (Patient #1, #2, #3, #4, #5, #6, and #7) 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 #1: There was evidence that the Spiritual Care Coordinator and the Social Worker have visit frequency of "initial and then 1 visit per month as needed." Corrected onsite. Patient #2: There was evidence that the Social Worker have visit frequency of "initial and may do 1 visit per month as needed" and the Spiritual Care Coordinator had a visit frequency of "initial and then 1-2 visits/week prn." Corrected onsite. Patient #3, #4, #5, #6, #7: There is evidence that the Social Worker have visit frequency of "initial and may do 1 visit per month as needed" and the Spiritual Care Coordinator had a visit frequency of "initial and then 1-2 visits prn." Corrected onsite for #3, #4 and #5.

Upon patient record review, 3 of 14 (Patient #1, 2, 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 #1: There is an order for "Oxygen 2-4 L inhalation as needed for shortness of breath which is not a correct mode of oxygen delivery. The Lidocaine 4%/menthol 1% 1 unit topical every 12 hours PRN pain is missing an application location. Lidocaine order was corrected on site. Patient #2: There was a treatment orders for Calmoseptine, Fleets enema, Dulcolax Suppository and oxygen PRN but they are not complete as they are missing the dose and the frequency. Patient #3: There is an order for Calmoseptine PRN missing the application location, frequency and indication. Corrected onsite.

Upon client record review, 4 of 14 (Patient #5, #6, #8 and #9) 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 visit frequency for the aide was indicated as 2x/week. There is no evidence that the aide made any visits to the patient. Patient #6: The visit frequency for the aide was indicated as 2x/week. There is no evidence that the aide made 2 visits the week of 6/16/25 or any visits the week of 6/23/25. There is no documentation to support why the visits were not made. Patient #8: The visit frequency for both the MSW and the SC is for 1 recert visit. There is no evidence of an order for the MSW visits made on 5/1/25 and 5/29/25 and for the SC visit made on 5/6/25. Patient #9: The visit frequency for the aide was 2x/week. The documentation revealed only one visit the weeks of 3/31/25 and 4/7/25.

Upon patient record review, 1 of 14 (Patient #1) 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 #1: The patient is on Eliquis and there is no bleeding precautions included on the aide care plan. There is documentation the patient is bedbound but the aide care plan says to provide a shower.

Upon patient record review 1 of 14 (Patient #1) 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 #1: Upon review of the record the aide care plan said to give the patient a shower but in 15 of 15 visits the aide documented that a bed bath was completed Upon review of the aide visit documentation in 14 of 15 visits it said a shampoo was completed but the care plan doesn't say to provide a shampoo. The 8/5/2025 visit documentation said the aide emptied the foley bag but task is not on the care plan. There was no documentation of a call to an RN to support the change of care provided.

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. Patient #1 During the home visit, the patient was noted to have Gabapentin 300mg and Valacyclovir 1GM included in his medication regimen. The medications have not been reviewed and included on the med profile, nor was a reconciliation conducted during the visit.

Upon patient record review, 1 of 5 (Patient #1) 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 Upon home visit, the patient medications included Gabapentin 300 mg tablets and Valacyclovir 1gm tabs that are not included in the plan of care.