Every finding on record at Arc Comfort Hospice Care Inc

Upon patient record review, 2 of 14 (Patient #1,2) 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 Patient #1, Patient is taking EC ASA every day. No evidence of ASA was documented on the medication profile. Patient #2, Patient is taking Sevelamer 800mg 3-4 tablets 3x/day with meals. Medication profile states Sevelamer 800mg 1 tablet 3x/day with meals.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,7,9) 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 #1,3,7,9, No evidence a funeral home was identified on MSW initial assessment. No care plan addressing funeral planning. Patient #2, Patient is a full code. No evidence of a care plan addressing patient full code status. Patient #4,5,6, No evidence a funeral home was identified on MSW initial assessment. No care plan addressing funeral planning. Patient is a full code. No evidence of a care plan addressing patient full code status.

Upon patient record review, 1 of 14 (Patient #4) 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 #4, LVN note on 8/2/25, documented "advised to apply Calmoseptine ointment to surrounding areas." No evidence of order documented for Calmoseptine ointment in plan of care.

Upon observation 1 of 3 home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, RN removed blood pressure cuff from the clean area, took patient's blood pressure then returned the blood pressure cuff back to the clean area where the other clean equipment was placed.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1,2,3,4,5,6,7,8,9,10, No evidence of clinical information added to the initial CTI.

Upon personnel record review, 1 of 7 applicable (Personnel #4) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel record #4: The record did not contain evidence of competency for the bereavement coordinator role.

Upon patient client record review, 1 of 5 records (Patient #2) 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. Patients #2: The record contained evidenced of ibuprofen 600 mg three times a day PRN, however RN stated this was documented in error and patient is not taking Ibuprofen. [corrected on site]