Every finding on record at Alpha-Omega Hospice, LP

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: Patient election statement includes space allocated to choose or not to choose physician. The space is blank, therefore, unable to verify patient's understanding and/or choice or decision not to choose.

Upon patient record review, 3 of 19 (Patient #2, 6, 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 #2: Patient admitted with implanted pain pump, filled/administering Morphine. There is no related alert or precaution included on medication profile. Patient #6: During patient visit, noted that facility medication profile includes: 3/5/26: Valproic Acid/Depakote 500 mg 2x/day for seizures. Patient #7: During patient visit, noted that facility medication profile includes: 5/11/26 Sliding Scale dosages for Humalog Insulin 4x/day, Mounjaro subcutaneous injections daily. Carvedilol 2x daily. The hospice medication profile does not include these medications.

Upon patient record review, 2 of 19 (Patient #2, 6) 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: Patient admitted with implanted pain pump, managed by pain physician, however, there is not evidence of related problems, goals, interventions. Patient #6: Patient has diagnosis of seizures with Keppra and Phenobarbital prescribed. There is no evidence of related problems, goals, interventions.

Upon patient record review, 1 of 19 (Patient #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 #7: 5/18/26 order for wound care Stage II Coccyx cleanse wound with wound cleanser, pat dry, apply collagen particles and triad and cover with clean dressing to be completed by facility and hospice SN. There is no documented frequency of wound care in order or plan of care.

Upon client record review, 1 of 19 records (Patients #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: MD order Volunteer offered and accepted. No evidence volunteer provided.

Upon patient record review 3 of 19 (Patient #1, 13, 15) 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: Patient admitted 4/15/26 with order 4/15/26 Volunteer offered and accepted. Volunteer Coordinator noted that Volunteer will be placed when available in patient area. There was no documented evidence that volunteer is available still, at time of survey. Patient #13: 2/17/26 Volunteer Coordinator Communication Note documented that patient volunteer was offered and accepted. Volunteer Coordinator to place on the request list and pair with a vol when one becomes available in the patients area. - no evidence provided or declined. Verified patient. Verified no notes scanned in. Patient #15: Patient admitted 3/28/26. RN documented patient accepted all services including volunteer. 4/8/26 IDG Volunteer Coordinator note Volunteer services accepted upon admission. Volunteer Coordinator continuing to try and meet this need. Appropriate volunteer will be placed when available in patient area. Discharged on 5/14/26 with no documented evidence of having received volunteer.

Upon 1 of 3 home visit observations, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5: RN failed to wipe equipment after using on patient. She place in pocket she referred to as dirty, but it was a slit pocket in the general bag space.

Upon patient record review, 2 of 19 (Patient #2, 6) 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 #2: Patient admitted with implanted pain pump. There is no alert to device included in hospice aide care plan. Patient #6: Patient has diagnosis of seizures with Keppra and Phenobarbital prescribed. There is no reference to seizure precautions included in hospice aide care plan.

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. Upon observation and interview, the agency is unable to demonstrate 5 percent cost savings. The agency's 2025 CY total Volunteer Cost Savings is documented as 0.139%

Upon patient client record review, 1 of 19 (Patient #2) 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 #2: Patient election statement includes space allocated to choose or not to choose physician. The space is blank, therefore, unable to verify patient's understanding and/or choice or decision not to choose.

Upon patient record review, 1 of 5 records (Patient #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 #5: The nurse documentation from admission (6/16/23) indicated that the patient was on oxygen at 2L via nasal cannula. Nurse documentation from 7/18/23 continued to indicate that the patient was wearing oxygen at 2-4L/min. There was not evidence of oxygen on the medication profile.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence the plan of care 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 record indicated the visit frequency for the skilled nurse as 1-2x/week and 10 prn.

Upon patient record review, 2 of 5 records (Patient #1, 5) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Nurse documentation dated 7/13/23, indicated that the patient wears Bi-Pap occasionally. There was not evidence of an order for Bi-Pap on the plan of care. Patient #5: The nurse documentation from admission (6/16/23) indicated that the patient was on oxygen at 2L via nasal cannula. Nurse documentation from 7/18/23 continued to indicate that the patient was wearing oxygen at 2-4L/min. There was not evidence of an order

Upon patient record review, 9 of 19 (Patient #1, #2, #3, #4, #7, #9, #10, #11, #12) did not have evidence in the patient record that a complete and accurate review of all prescription and non-prescription medications was performed. Patient #1-The medication profile includes the following meds which are ordered prn without symptoms/indications for administration: Levsin, Acetaminophen Rectal suppositories , Hydrocodone-Acetaminophen, Morphine, Zofran and Lorazepam. (corrected on site) Patient #2- The medication profile includes scheduled Morphine; Morphine 20mg/ml .25-1ml qhr po (inaccurate as medication ordered for prn administration). Acetaminophen suppositories are also ordered 650 mg q6h per rectum scheduled. (inaccurate as ordered prn). Levsin, Hydroxyzine, Imodium, Tylenol ES, Promethazine, and Hydrocodone-Acetaminophen are listed on the profile as prn medications without indications for administration. Oxygen is listed as 02 2-4 liters q shift via nose prn. (corrected on site) Patient #3- Lorazepam and Tramadol are listed on the medication profile as prn medications without indications for administration. MiraLax is listed as 17 gm 1 scoop powder daily. A diluent is not listed. Lumigan Ophthalmic eye drops are listed as .01% 1 gtt at Hs. The profile does not specify which eye(s). (corrected on site) Patient #4-The medication profile includes Tramadol, Zofran and Tylenol suppositories as prn medications without indications for administration. (corrected on site) Patient #7-The medication profile contains the following medications ordered as scheduled medications: Acetaminophen suppository 650 mg q6h per rectum, Dulcolax suppository 10 mg qd per rectum, Levsin .125 mg 1 tab every 2 hours, Morphine Sulfate 20 mg/ml .25 ml-1ml every hour po. (inaccurate as the medications were ordered for prn administration). Promethazine and Lorazepam are listed as prn medications without indications for administration. (corrected on site) Patient #9-The medication profile includes the following medications listed as prn without indications for use: Acetaminophen rectal suppository, Ativan, Dulcolax rectal suppository, Levsin, Ondansetron, Oxygen, Prochlorperazine Maleate, and Promethazine. (corrected on site) Patient #10-The medication profile includes multiple scheduled medications which were to be ordered as prn medications: Morphine 20mg/ml .25ml qhr po, Acetaminophen suppositories are also ordered 650 mg q6h per rectum scheduled. Levsin .125 mg 1 tab every 2 hours and Ducolax rectal suppository 10 mg qd PR, Acetaminophen -Codeine 300-30mg is ordered 1 tab q4h, Zofran 1 tab q4h, and Lorazepam .5mg 1 tab q4h po. (corrected on site) Patient #11-The medication profile includes Tylenol 325 mg tab as needed po (the number of tabs and indications for prn administration is not listed on the profile). (corrected on site) Patient #12-The medication profile includes Nitroglycerin SL .4mg tab 1 tab prn sublingual. (the profile does not include frequency/maximal number of doses and indications for administration).

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

Upon patient record review, 1 of 19 (Patient #12) 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 #12-Effective 05/09/23 Social Worker and Spiritual Care provider are ordered prn. (prn can not be a sole frequency)

Upon patient record review, 10 of 19 (Patient #1, #2, #3, #4, #7, #9, #10, #11, #12, #13) 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 specific/accurate orders for all medications and treatments. Patient #1-The plan of care includes the following meds which are ordered prn without symptoms/indications for administration: Levsin, Acetaminophen Rectal suppositories , Hydrocodone-Acetaminophen, Morphine, Zofran and Lorazepam. (corrected on site) Patient #2- The plan of care includes scheduled Morphine; Morphine 20mg/ml .25-1ml qhr po. Acetaminophen suppositories are also ordered 650 mg q6h per rectum scheduled. (Morphine and Acetaminophen suppositories were ordered prn) Levsin, Hydroxyzine, Imodium, Tylenol ES, Promethazine, and Hydrocodone-Acetaminophen are listed on the plan of care as prn medications without indications for administration. Oxygen is listed as 02 2-4 liters q shift via nose prn. (corrected on site) Patient #3- Lorazepam and Tramadol are listed on the plan of care as prn medications without indications for administration. MiraLax is listed as 17 gm 1 scoop powder daily. A diluent is not listed. Lumigan Ophthalmic eye drops are listed as .01% 1 gtt at Hs. The plan of care does not specify which eye(s). (corrected on site) Patient #4-The plan of care includes Tramadol, Zofran and Tylenol suppositories ordered as prn medications without indications for administration. (corrected on site) Patient #7-The plan of care contains the following medications ordered as scheduled medications: Acetaminophen suppository 650 mg q6h per rectum, Ducolax suppository 10 mg qd per rectum, Levsin .125 mg 1 tab every 2 hours, Morphine Sulfate 20 mg/ml .25 ml-1ml every hour po. (The medications were ordered prn for symptom management).Promethazine and Lorazepam are listed as prn medications without indications for administration. (corrected on site) Patient #9-The plan of care includes the following medications listed as prn without indications for use: Acetaminophen rectal suppository, Ativan, Dulcolax rectal suppository, Levsin, Ondansetron, Oxygen, Prochlorperazine Maleate, and Promethazine. (corrected on site) Patient #10- The patient was admitted with a Foley catheter and the plan of care does not address management of the Foley. The plan of care includes multiple scheduled medications which were to be ordered as prn medications: Morphine 20mg/ml .25ml qhr po, Acetaminophen suppositories are also ordered 650 mg q6h per rectum scheduled. Levsin .125 mg 1 tab every 2 hours and Ducolax rectal suppository 10 mg qd PR, Acetaminophen -Codeine 300-30mg is ordered 1 tab q4h, Zofran 1 tab q4h, and Lorazepam .5mg 1 tab q4h po. (corrected on site) Patient #11-The plan of care includes Tylenol 325 mg tab as needed po (the number of tabs and indications for prn administration is not listed on the plan of care).(corrected on site) Patient #12-The plan of care includes Nitroglycerin SL .4mg tab 1 tab prn sublingual. (the plan does not include frequency/maximal number of doses and indications for administration). Patient #13- The plan of care includes orders to cleanse the patients Bilateral Lower extremity wounds . Orders are to cleanse the wounds with NS, apply collagen and anasept, cover with bordered gauze or Kerlix. The frequency for wound care is not included in the orders

Upon patient record review, 7 of 19 (Patient #1, #2, #3, #4, #7, #18, #19) 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 #1, #2, #7-The 05/10/23 and 05/24/23 IDG/revised plan of care documentation by the nurse only indicates the IDG met and a review of the patient occurred including admission, current care plan needs , meds, falls, disaster preparedness and grief/bereavement needs. The documentation is not patient specific regarding the physical needs of the patient and does not evidence the patient's progress towards outcome/goals from the plan of care. Patient #3, #4- The 05/24/23 IDG/revised plan of care documentation by the nurse only indicates the IDG met and a review of the patient occurred including current care plan needs. meds, falls, infection, disaster preparedness and grief/bereavement needs. The documentation is not patient specific regarding the physical needs of the patient and does not evidence the patient's progress towards outcome/goals from the plan of care. Patient #18-The 12/07/22 IDG/revised plan of care documentation performed by the social worker is inaccurate. The SW documents the patient is residing in a skilled facility. The social worker documents care planning needs were discussed and the Social Worker would provide monthly contacts with Facility and the patient's family. The patient died on 11/24/22. Patient #19-On 03/15/23 there is IDG documentation that the IDG met and reviewed the patients passing. The record reads: The patient passed away peacefully, family was grieving well, and accepting of bereavement services. The documentation is inaccurate as the patient revoked the Hospice benefit on 03/10/23 to seek aggressive treatment.

Upon patient record review, 4 of 19 (Patient #1, #2, #8, #10) 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 05/25/23 the nurse documented wound care was provided as ordered. The record does not contain orders for wound care. (corrected on site) Patient #2- On 05/03/23 the nurse documented removing sutures from the patients eyebrow and under eye area. The record does not contain orders for suture removal. (corrected on site) Patient #8- On 04/04/23 the nurse documented performing a disimpaction. There are no orders on record for the disimpaction. (corrected on site) Patient #10-On 05/26/23 the nurse documented the patients Foley catheter was flushed with 60 cc Normal Saline. There are no orders on record to flush the catheter. (corrected on site)

Upon patient record review, 3 of 19 (Patient #17, #18, #19) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patient # 17, #18, #19-Each of the bereavement plans of care document interventions as an initial contact will be performed and an annual memorial service will be conducted. Interventions also read provide appropriate level of bereavement based on risk score. The interventions between the initial contact and annual memorial service are not specific on the plan of care to define the services to be provided.

Upon patient record review 7 of 19 (Patient #4, #5, #6, #7, #8, #10, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: ordered by the interdisciplinary group and included in the plan of care. (late entry missed visit documentation corrections were made on site) Patient #4-The Aide is ordered to visit 5 times weekly. Between 4/30 and 6/2/23 the Aide visited 3-4 times weekly. There is no documentation regarding the missed visits on record. Patient #5- The Aide is ordered to visit 5 times weekly. The week of 05/21/23 the Aide visited three times. The week of 05/28/23 the Aide visited 4 times. There is no documentation regarding the missed visits on record. Patient #6-The Aide is ordered to visit 5 times weekly. The week of 05/21/23 the Aide visited three times. There is no documentation regarding the missed visits on record. Patient #7- The Aide is ordered to visit 5 times weekly. Between 04/30/23 and 05/28/23 the Aide visited twice weekly. There is no documentation regarding the missed visits on record. Patient #8- The Aide is ordered to visit 5 times weekly. Between 05/07/23 and 05/28/23 the Aide visited twice weekly. There is no documentation regarding the missed visits on record. Patient #10- The Aide is ordered to visit 2 times weekly effective 04/21/23. The first aide visit on record did not occur until 05/03/23. Between 05/10/23-06/02/23 the Aide visited three to four times weekly. Patient #13- The Aide is assigned to perform a shower on Monday , Wed, and Fridays. Between 05/15/23 and 06/07/23 the Aide only performed one Shower on 05/24/23. Bed Baths were performed instead. Bed Baths were assigned for Tues and Thursdays visits only.

Upon patient record review, 3 of 19 (Patient #1, #10, #12) did not have evidence that all entries are complete and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1-The nurse documented on 05/25/23 wound care was provided as ordered. The documentation is not specific for the actual wound care performed. Patient #10-The nursing visit notes between 04/21/23-05/05/23 do not include credentials as part of the electronic signature. The 06/02/23 Social Worker visit note does not include credentials as part of the electronic signature. Patient #12-The 05/28/23 nursing visit note does not include employee credentials as part of the electronic signature.