Every finding on record at All Star Hospice, Inc.

Upon patient record review, 2 of 19 (Patient #1,7) 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 current medication record dated 01/26/26 contains Tylenol Suppository 650mg q6 hours, Hydrocodone-Acetaminophen 10/325 three times daily and q6 hours prn. There is no directive of maximum daily limit of acetaminophen. Patient 7: The current medication record dated 01/26/26 includes Voltaren 1% gel. Order does not include a site of application.

Upon patient record review, 2 of 19 (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. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4: The current POC dated 01/26/26 includes orders for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 5: The current POC dated 01/26/26 includes orders for aspirin. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions.

Upon patient record review, 2 of 19 (Patient #1,7) 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 current POC dated 01/26/26 contains orders for Tylenol Suppository 650mg q6 hours, Hydrocodone-Acetaminophen 10/325 three times daily and q6 hours prn. There is no directive of maximum daily limit of acetaminophen. Patient 7: The current POC dated 01/26/26 contains orders for Voltaren 1% gel order does not include site of application.

Upon client record review, 4 of 13 (Patients #1, 5, 6 and 7) 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 POC listed Skilled Nursing visit frequency of 3 X's per week ordered 1/28/23. For the benefit week 1/22/23 there were only 2 SN visits made on 1/24/23 and 1/28/23. Patient #5: The POC listed Skilled Nursing visit frequency of 7 X's per week. For the first benefit week, there was only 1 SN visit made on 1/17/23. Patient #6: The POC listed Skilled Nursing visit frequency of 5 X's per week. For first benefit week, there were only 2 SN visits made on 11/10/22 and 11/11/22. Patient #7: The POC listed Skilled Nursing visit frequency of 2 X's per week. For benefit weeks 11/20/22 and 11/27/22 the visit frequency was not met. The week of 11/20/22 only 1 SN visit was made. The week of 11/27/22, no SN visits were made.

Upon patient record review 5 of 13 (Patients #2, 4, 6, 7 and 12) 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 Patient # 2: The POC listed Aide visit frequency of 2 X's per week. For first benefit week, there was only 1 aide visit on 1/14/23. Patient # 4: The POC listed Aide visit frequency of 2 X's per week. For first benefit week, there were no aide visits made. Patient # 6: The POC listed Aide visit frequency of 2 X's per week per order on 11-10-22. There were no aide visits made until 12/27/22. Patient # 7: The POC listed Aide visit frequency of 3 X's per week. For first benefit week, there were only 2 visits on 11/16/22 and 11/17/22. Patient #12: The POC listed Aide visit frequency of 3 X's per week. For first benefit week, there was only 1 aide visit on 8/27/22.

Upon patient client record review, 13 of 13 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1 through #13: There is no evidence the beneficiary elected or declined to receive the "Patient Notification of Hospice Non Covered Items". Agency is using 2004 EOB form that does not include this choice on the form. The patient handbook does have QIO contact information.