Every finding on record at Ave Maria Hospice Inc.

Upon patient record review, 2 of 14 (Patient #3,8) 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 3: Patient has 10/2/23 order (renewed 5/22/24) for bisacodyl suppositories. There is no evidence of application frequency documented on the medication profile. Patient has a 10/2/23 order for ProctoMed HC(renewed 5/22/24). There is not evidence of an application site documented on the medication profile. Patient has 11/28/23 order for mometasone furoate 0.1 percent (renewed 5/2/24): There is not evidence of an application site documented on the medication profile. Patient has 5/22/24 order for triamcinolone 0.1 percent. There is not evidence of an application site documented on the medication profile. Patient 8: Patient has 3/1/24 order for Ciprodex 0.3 percent-0.1 percent otic suspension. There is no evidence of application frequency or application site documented on the medication profile. Patient has 3/1/24 order for Lidocaine 5 percent transdermal patch. There is no evidence of frequency, duration or application site documented on the medication profile.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 2: There is no evidence of initial bereavement assessment in this patient's medical record.

Upon patient record review, 4 of 14 (Patient #1,2,7,9) 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: There is not evidence of bleeding precautions documented in patient's in plan of care, despite physician's order for daily anticoagulation with Xarelto. Patient 2: There is not evidence of bleeding precautions documented in patient's in plan of care, despite physician's order for daily anticoagulation with clopidogrel. Patient 7: There is not evidence of bleeding precautions documented in patient's in plan of care, despite physician's order for daily anticoagulation with Plavix and aspirin. Patient 9: There is not evidence of bleeding precautions documented in patient's in plan of care, despite physician's order for daily anticoagulation with Eliquis.

Upon patient record review, 3 of 14 (Patient #2,3,8) 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 2: Patient has order for diclofenac as ordered on 5/25/24: Diclofenac 2 percent. 2G to affected area. Indication states for arthritis/knee pain. During LVN visit made on 6/7/24, LVN documented the following: patient has moderate pain 4/10 in lower back. SN applied diclofenac sodium 2 percent topically to lower back. There is no evidence in patient's plan of care order that this is an appropriate application site. Patient 3: Patient has 10/2/23 order (renewed 5/22/24) for bisacodyl suppositories as follows: bisacodyl 10mg suppositories. One suppository PR, PRN/constipation. There is no evidence of application frequency documented in the plan of care orders. Patient has a 10/2/23 order for ProctoMed HC(renewed 5/22/24): ProctoMedHC 2.5 percent topical 28 gram. Apply topically to affected area daily for itching. There is not evidence of an application site documented in the plan of care orders. Patient has 11/28/23/23 order for mometasone furoate 0.1 percent (renewed 5/2/24): Mometasone furoate 0.1 percent topical. Apply 0.5gram to affected area twice daily. There is not evidence of an application site documented in the plan of care orders. Patient has 5/22/24 order for triamcinolone 0.1 percent: triamcinolone 0.1 percent. Apply 1 gram to affected area three times daily. There is not evidence of an application site documented in the plan of care orders. Patient 8: Patient has 3/1/24 order for Ciprodex 0.3 percent-0.1 percent otic suspension: Ciprodex otic suspension. One drop as needed for chronic ear infection. There is no evidence of application frequency or application site in the plan of care orders. Patient has 3/1/24 order for Lidocaine 5 percent transdermal patch: Apply one patch to affected area for pain. There is no evidence of frequency, duration, application site in the plan of care orders.

Upon patient record review, 1 of 14 (Patient #2) 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 2: There is not evidence of aspiration precautions documented in recert visit dated 4/30/24.

Upon client record review,10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There is no evidence in medical record of LVN visit made after 6/9/24. Frequency order written on 4/2/24 is for weekly visits. Patient 2: Patient has 5/25/24 order for diclofenac. Indication states for arthritis/knee pain. During LVN visit made on 6/7/24, LVN documented the following: patient has moderate pain 4/10 in lower back. SN applied diclofenac sodium 2 percent topically to lower back. There is not evidence in the medical record that this is an appropriate application site. Patient 3: Order written 10/2/23 for initial SC evaluation within 5 days of admission. Order written 10/4/23 for monthly visits. No evidence of second SC visit made during month October 2023. Order written 10/2/23 for initial MSW evaluation within 5 days of admission. Order written 10/4/23 for monthly visits. No evidence of second MSW visit made during month October 2023. Patient 4: Order written 4/11/24 for initial SC evaluation within 5 days of admission. Order written 4/12/24 for monthly visits. No evidence of second SC visit made during month April 2024. Order written 4/11/24 for initial MSW evaluation within 5 days of admission. Order written 4/14/24 for monthly visits. No evidence of second MSW visit made during month April 2024. Patient 5: Order written 4/4/24 for initial SC evaluation within 5 days of admission. Order written 4/5/24 for monthly visits. No evidence of second SC visit made during month April 2024. Order written 4/4/24 for initial MSW evaluation within 5 days of admission. Order written 4/6/24 for monthly visits. No evidence of second MSW visit made during month April 2024. Patient 6: Order written 4/2/24 for initial SC evaluation within 5 days of admission. Order written 4/4/24 for monthly visits. No evidence of second SC visit made during month April 2024. Order written 4/2/24 for initial MSW evaluation within 5 days of admission. Order written 4/4/24 for monthly visits. No evidence of second MSW visit made during month April 2024. Patient 7: Order written 3/22/24 for initial SC evaluation within 5 days of admission. Order written 3/24/24 for monthly visits. No evidence of second SC visit made during month March 2024. Order written 3/22/24 for initial MSW evaluation within 5 days of admission. Order written 3/25/24 for monthly visits. No evidence of second MSW visit made during month March 2024. There is no evidence in the medical record of LVN visit made after 6/9/24. Patient 8: Order written 3/1/24 for initial SC evaluation within 5 days of admission. Order written 3/3/24 for monthly visits. No evidence of second SC visit made during month March 2024. Order written 3/1/24 for initial MSW evaluation within 5 days of admission. Order written 3/3/24 for monthly visits. No evidence of second MSW visit made during month March 2024. There is no evidence in the medical record of LVN visit made after 6/9/24. Patient 9: Order written 11/25/23 for initial SC evaluation within 5 days of admission. Order written 11/27/23 for monthly visits. No evidence of second SC visit made during month November 2023. Order written 11/25/23 for initial MSW evaluation within 5 days of admission. Order written 11/27/23 for monthly visits. No evidence of second MSW visit made during month November 2023. Patient 10: Order written 10/5/23 for initial SC evaluation within 5 days of admission. Order written 10/6/24 for monthly visits. No evidence of second SC visit made during month October 2023. There is no evidence in the medical record that SC visited patient in November 2023. Order written 10/5/24 for initial MSW evaluation within 5 days of admission. Order written 10/6/24 for monthly visits. No evidence of second MSW visit made during month October 2023.

Upon inpatient contract review, 1 of 3 (contract Alexandria Care Center) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon SNF/NF contract review, 1 of 3 (contract Alexandria Care Center) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.