Every finding on record at Astra Hospice Care, Inc.

Upon patient record review, 3 of 14 (Patient #1,3,10) 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 RN initial assessment stated, "IV antibiotic Invanz 1 gm. IV push daily". The antibiotic was not listed on the medication list. Patient #3: The patient is on O2 precautions and there is an order for an O2 concentrator with O2 tanks. Oxygen is not on the medication list. Additionally, on the home visit, Losartan was not in the home. The PCG stated the patient was told by his doctor to stop taking over a month ago. (Both items corrected on site.) Patient #10: There is evidence of an order for an O2 concentrator with O2 tanks. Oxygen is not on the medication list. (Corrected on site)

Upon patient record review, 4 of 14 (Patient #1,2,3,4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: The plan of care indicated RN visit every 14 days. There were RN visits on 11/5/24 and 11/12/24. There is no evidence of an RN visit on 11/26/24 or 12/11/24. Patient #2: The plan of care indicated RN visit every 14 days. There were RN visits on 11/15/24 and 11/29/24. There is no evidence of an RN visit on 12/12/24. Patient #3: The plan of care indicated RN visit every 14 days. There were RN visits on 10/25/24, 11/8/24, 11/22/24. There is no evidence of an RN visit on 12/4/24. Patient #4: The plan of care indicated RN visit every 14 days. There were RN visits on 10/23/24 and 11/6/24. There is no evidence of an RN visit on 11/20/24 or 12/4/24.

Upon patient record review, 1 of 14 (Patient #1) 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: The initial RN assessment indicated the patient was on an antibiotic for kidney infection. The plan of care did not contain a problem for infection.

Upon patient record review, 3 of 14 (Patient #1,3,10) 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 RN initial assessment stated, "IV antibiotic Invanz 1 gm. IV push daily". There was no order for the antibiotic. Additionally, there was no order for the IV or IV dressing change. Patient #3: The patient is on O2 precautions and there is an order for an O2 concentrator with O2 tanks. There is no order for Oxygen on the plan of care. (Corrected on site) Patient #10: There is an order for an O2 concentrator and O2 tank for O2 nasal administer as needed for SOB. The order does not include dosage. Additionally, there is an order from 3/5/24 for Medi honey to apply to small wound which is no longer active. (Corrected on site)

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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: The RN assessment on admission indicated the patient was continent of urine. On 12/9/24, the SN note indicated "patient needs maximum assistance in ADLs is incontinent of bladder. The plan of care was not updated to include incontinence of urine. (corrected on site) In addition, there is no evidence in the medical record that all members of IDG were present on 11/22/24 as no members signed the IDG Review. Additionally on 12/6/24, no members signed the IDG Review. Patient #2,4,7,9: There is no evidence in the medical record that all members of IDG were present on 11/22/24 and 12/6/24 as the MSW and RN did not sign the IDG Reviews. Patient #3: There is no evidence in the medical record that all members of IDG were present on 11/22/24 as the MSW and RN did not sign the IDG Review. Additionally on 12/6/24, the MSW did not sign the IDG Review. Patient #5,6,8,10: There is no evidence in the medical record that all members of IDG were present on 11/22/24 and 12/6/24 as the MSW did not sign the IDG Reviews. Patient #8: The RN assessment noted on 12/12/24 that the patient sleeps 5 hrs./day and on 12/16/24 Ambien was add to the medication list. The plan of care was not updated for insomnia.(corrected on site) Patient #10: There is an order on 11/12/24 for Duo Neb Nebulizer treatment. Treatment is not included in the plan of care. (corrected on site)

Upon patient record review, 4 of 14 (Patient #2,4,8,9) 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 #2: There is evidence in the medical record for the benefit period #1, 8/23/24-11/20/24, the Medical Director Certification of Terminal Illness for does not contain written documentation of clinical details. The CTI states in part "dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #4: There is evidence in the medical record for the benefit period #1, 10/23/24-1/20/25, the Medical Director Certification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #8: There is evidence in the medical record for the benefit period #1, 9/5/24-12/3/24, the Medical Director Certification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #9: There is evidence in the medical record for the benefit period #1, 8/6/24-11/3/24, the Medical Director Certification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline".

Upon patient record review, 9 of 14 (Patient #1,2,3,5,6,7,8,9,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: There is evidence in the medical record for admission into benefit period #2, 11/5/24-2/2/25, the Medical Director Recertification of Terminal Illness for does not contain written documentation of clinical details of prognosis. The CTI states in part, "dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #2: There is evidence in the medical record for benefit period #2, 11/21/24-2/18/25, the Medical Director Recertification of Terminal Illness for does not contain written documentation of clinical details for prognosis. The CTI states in part, "The PCG understands prognosis and no longer plans to seek aggressive treatment and just wanted comfort measures. See nursing notes for specific details on decline". Patient #3: There is evidence in the medical record for the admission into benefit period #4, 10/25/24-12/23/24, the Medical Director Recertification of Terminal Illness for does not contain written documentation of clinical details of prognosis. The CTI states in part "dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #5: There is evidence in the medical record for the admission into benefit period #2, 10/17/24-1/14/25, the Medical Director Recertification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #6: There is evidence in the medical record for the admission into benefit period #2, 9/26/24-12/24/24, the Medical Director Recertification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #7: There is evidence in the medical record for the admission into benefit period #2, 9/17/24-12/15/24, the Medical Director Recertification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Additionally, for recertification of terminal illness into benefit period #3 12/16/24 to 2/13/24, the Medical director did not sign the attestation or write a certifying narrative. Patient #8: There is evidence in the medical record for benefit period #2, 12/4/24-3/3/25, the Medical Director Recertification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #9: There is evidence in the medical record for benefit period #2, 11/4/24-2/1/25, the Medical Director Recertification of Terminal Illness does not contain documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline". Patient #10: There is evidence in the medical record for the benefit period #14, 12/4/24-2/1/25, the Medical Director Recertification of Terminal Illness for does not contain written documentation of clinical details as to a 6 month life expectancy. The CTI states in part, ""dx/comorbidities are consistent with terminal prognosis of 6 months or less. See nursing notes for specific details on decline".

Upon personnel record review, 3 of 14 (Personnel #9,10,11) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Upon review of contracted employee files, the PT/OT/ST contractor used the National Practitioner Data Bank report for background checks. It does not list "criminal" background check. It does list no Judgment or conviction reports. However, the therapy contractor could not verify that the Data bank identified misdemeanors and felonies in the past 3 years of searched individuals.

Upon patient record review, 1 of 1 applicable (Patient #4) 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 #4 The 9/4/21 aide care plan did not contain a task frequency with the following associated tasks: shower, hair care, mouth care, nail care and housekeeping.