Every finding on record at Berkley Palliative Care and Hospice, LLC

Upon patient record review, 1 of 5 (Patient #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 2: On the medication profile there are medications: Famotidine, Riluzole, Glycopyrrolate, MiraLAX, Guaifenesin, Morphine sulphate, Lorazepam, and Isosource 1.5 Cal. The patient's diet order is NPO and has a G-tube, the route should be via g-tube. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: On 9/26/25 and 10/1/25 in the RN assessment there is documentation that the patient has a g-tube, there is no evidence that the SN assessed the g-tube site or provided any wound care for g-tube. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) 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: On the plan of care there are medications: Famotidine, Riluzole, Glycopyrrolate, MiraLAX, Guaifenesin, Morphine sulphate, Lorazepam, and Isosource 1.5 Cal. The patient's diet order is NPO and has a G-tube, the route should be via g-tube. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: On the RN comprehensive assessment there is documentation of g-tube care, there are no orders on the plan of care for the care of the g-tube. Corrected on site with an addendum to the record.

Upon patient record review 2 of 14 (Patient #8,12) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 8: The SC did not completed a SC assessment and has not seen the patient, patient refused SC. The RN did not complete the assessment during the comprehensive assessment. Patient 12: The chaplain was refused, the RN did not complete a spiritual care assessment as part of the comprehensive assessment. Pt has not been seen by spiritual care.

Upon patient record review, 5 of 14 (Patient #1,7,8,9,14) 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: Patient 1: The medication profile contains an order for Hydrocortisone 1 application topical every 6 hours as needed for redness/irritation- Order does not indicate a site of application; Patient has an order for Lidocaine 1 application topical every 6 hours as needed for pain - does not indicate a site of application. Corrected on site, order updated. Patient 2: The medication profile lists voltaren arthritis topical with no site to apply. Corrected on site, medication discontinued. Patient 7: Patient has an order on the medication profile for Lidocaine 5% patch without indication of site for application. Corrected on site, order updated. Patient 8: The current medication profile contains Diclofenac topical apply 1 time daily prn for pain with no site. Corrected on site, order updated. In addition, Miralax powder is ordered daily prn with no diluent. Patient 9: The medication profile contains orders for Acetaminophen 325, 2 tabs twice daily and 2 tabs every 4 hours prn for pain/fever. There is no directive not to exceed 4000mg daily of acetaminophen. Corrected on site, order updated. Patient 14: The medication profile lists diphenhydramine 1 application topically 3 times daily as needed for itching. There is no site for application. Corrected on site, order updated.

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

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: The patient has new wounds documented beginning 7/29/25, there is no evidence of the SN measuring the wounds or assessing the wounds. On 8/5 the SN documents the facility is performing wound care, SN from hospice did not assess. On 8/7 the SN documented that the facility has already performed dressing change and the dressing was clean dry and intact. No measurements or assessment of wound by hospice nurse. On 8/12 the hospice SN documents assessing the wound and that the patient was stoic during assessment though there were no assessment findings documented or measurements of the wound. On 8/14 hospice SN documented “continues to have wounds on toes, facility changing dressing routinely, declined needing help with wound care. No measurements or assessment completed by hospice SN. Per agency policy, wounds are to be visualized and measured weekly.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 12: The SN documented on 7/17/25 patient is a current smoker and oxygen was added PRN in the past couple of days. There was no evidence of oxygen safety education being completed.

Upon patient record review, 2 of 14 (Patient #3,6) 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 3: Patient has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected onsite, care plan updated. Patient 6: Patient has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions; Initial comprehensive assessment indicates patient has a history of infection. There is no evidence of a plan of care established for risk of infections, UTI & drain sites with interventions and goals. Corrected on site, care plan updated.

Upon patient record review, 9 of 14 (Patient #1,2,6,7,8,9,11,12,14) 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 POC contains an order for Hydrocortisone 1 application Topical every 6 hours as needed for redness/irritation- does not indicate a site of application and Lidocaine 1 application Topical every 6 hours as needed for pain - does not indicate a site of application. Corrected on site. Patient 2: The POC current contains an order for voltaren arthritis topical with no site to apply. Corrected on site, medication discontinued. Patient 6: Patient has an Aspira Drain with orders to drain every other day without indication of who it is that will complete task with parameters how much to drain and how often, corrected on site. Patient 7: The current POC has an order for Lidocaine 5% patch without indication of site for application. Corrected on site, site of application added. Patient 8: The current POC contains diclofenac topical apply 1 time daily prn for pain with no site; Corrected onsite, site of application added. Miralax powder is ordered daily prn with no diluent. Corrected onsite, order updated. Patient 9: The current POC contains orders for Acetaminophen 325, 2 tabs twice daily and 2 tabs every 4 hours prn for pain/fever. There is no directive not to exceed 4000mg daily of acetaminophen. Corrected on site, order updated. Patient 11: Foley catheter order does not include balloon size, orders for change or flush or who will be performing tasks. Corrected on site, orders update. Patient 12: The updated POC contains an aide POC and the aide has been declined. In addition, the POC contains orders for the SN once weekly. The SN did not make a visit the week of 7/6-7/12/25. There is no evidence of missed visit documentation or refusal; The SN documented 7/28/25 “the family offers Ensure when patient does not eat”. Ensure is not on the POC. Corrected on site, Ensure added. Patient 14: The POC contains an order for diphenhydramine 1 application topically 3 times daily as needed for itching. There is no site for application; There is an aide POC on the POC 6/25/25. The patient refused the aide. Corrected on site, order updated.

Upon patient record review, 4 of 14 (Patient #3,4,9,14) 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 equipment and supply needs. Patient 3: DME indicated to be in use include on Aide care plan includes Hospital bed, O2, Hoyer lift and high back wheelchair. Equipment is not listed on the POC. Corrected on site. Patient 4: SN documented on POC patient has no DME though documented on comprehensive assessment patient uses a walker. Corrected on site, DME order added. Patient 9: The current POC has no DME listed. The SN documented 7/29/25 patient is up to wheelchair. Corrected on site, DME order added. Patient 14: The SN documented on 7/9/25 patient does not like her hospital bed. The hospital bed is not listed on the POC. Corrected on site, order for bed added.

Upon patient record review, 1 of 14 (Patient 12) 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 12: The SN documented 7/17/25 patient is a current smoker and oxygen was added in the past couple of days. There was no nursing care plan with goals or interventions initiated; SN documented “Pt weak and at risk for falls” on 7/24/25 there was no fall risk care plan initiated with goals and interventions. Corrected on site, care plans added.

Upon patient record review 1 of 14 (Patient #14) 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 14: Pt complains of disliking her hospital bed and wants her own bed on 7/9/25 and the SN mentions will follow up to see if they can get her old bed back. There has not been any follow up.

Condition of Participation: Hospice Aide and Homemaker Services.

Upon personnel record review, 1 of 15 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel 6: The aide did not have evidence of a competency to perform a tub bath, shampoo in sink, and bed bath.

Upon patient record review, 10 of 14 (Patient # 1,2,3,4,5,6,8,9,10,11) 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 1:Aide POC does not indicate a frequency for the tasks of clothing assist, complete bed bath, oral care, perineal care, shampoo, skin care. Corrected on site, aide POC updated. Patient 2: The aide POC contains all tasks with no frequencies except to change linens every visit. Corrected on site, aide POC updated. Patient 3: The aide POC does not indicate a frequency for the following tasks: clothing assist, complete bed bath, oral care, perineal care, shampoo, skin care. Corrected on site, aide POC updated. Patient 4: The current aide POC contains encourage fluids, barrier products in use with no frequency. Corrected on site, aide POC updated. Patient 5 The current aide POC does not include a frequency for bed bath, clothing assist, oral care, perineal care, shampoo, lotion application, Corrected on site, aide POC updated, Patient 6: The Aide POC does not indicate a frequency for repositioning, barrier cream application, site of application, encourage fluids, clothing assist, complete bed bath, oral care, perineal care, shampoo and lotion. Corrected on site, aide POC updated. Patient 8: The current aide POC contains tasks ordered though none of the tasks have frequencies. Corrected on site, aide POC updated. Patient 9: The current aide POC has all tasks ordered with no frequency accept to change bed linens each visit. Corrected on site, aide POC updated. Patient 10: The current aide POC include use of barrier product without location or frequency; Frequency not included in initial Aide plan of care for clothing assist, oral care, perineal care, shampoo, shower or lotion. Corrected on site, aide POC updated. Patient 11: The current aide POC does not include frequency for clothing assist, oral care, perineal care, shampoo, shave, shower or lotion. Corrected on site, aide POC updated.

Upon patient record review 3 of 14 (Patient #4,8,9) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4: Aide is ordered twice a week on current POC the aide saw patient 7/10 then not again until 7/16. There was no missed visit documentation or evidence of refusal. Aide saw patient July 22,23,25 and July 28, 29, August 1 with no order to increase visits. Last aide visit documented was 8/8 there are no missed visits documented or evidence of refusal. Aide visit 7/28/25 the aide is ordered to ambulate patient, bathroom assist, encourage fluids, clothing assist, oral care, peri care these items were not completed. Patient 8: The current POC has orders for aide twice weekly. The aide visited the patient 8/4, 8/5, 8/8 and 8/12, 8/14, 8/15 with no evidence of an order to increase aide visits. Patient 9: The POC contains orders for aide twice weekly. The week of 7/13-7/19 no second visit was made by the aide. There was no missed visit documentation, evidence of refusal or orders to decrease visits. The aide did not document completing any of their ordered tasks on 8/8/25. The aide did document “Client refused bed bath, notify the nurse on staff and will let Berkely know as well". There were also orders to change linens, dress patient, encourage fluids and these were not completed.

Upon patient record review, 3 of 14 (Patient #2,12,14) 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. Patient 2: SN documented 7/25/25 “Cleansed area and applied new dry dressing.” It is unclear what the wound was cleansed with. On 7/30 the SN documented “Cleansed area and applied new 4x4 dressing.” It is unclear what the wound was cleansed with. On 8/11 the SN documented “changed the dressing on patient's right hand” The details of the wound care are not clear. 8/15 The SN documented “this RN completed the wound care”. The details of the wound care are not clear. Patient 12: The SN documented “nttp” this is not an approved abbreviation. Patient 14: The SN noted patient to have a new wound on 7/30/25 and documented increasing SN visits to twice weekly due to wound. There is no order to increase the SN visits back up to twice a week and the SN continued to see the patient only one time per week and on the SN note 8/4/25 the SN documents she is being seen twice weekly by SN.

Upon patient record review, 5 of 14 (Patient #2,5,8,9,14) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: 7/28/25 the SN documented performing wound care to the right hand by removing the dressing and cleaning it, though did not document reapplying a dressing. In addition, patient is on long term ASA no risk for bleeding care plan with goals and interventions on the updated POC. Corrected on site, care plan added. Patient 5: RN visit note dated 8-19-25 states, “deep tissue injury measuring 0.5cm x 0.25cm as a stage 1 from sheering. Mepilex placed. Skin around area is blanchable, clean and dry, but very red.” Orders obtained 8/19/25 from Dr. Gagandeep Singh: Zinc Oxide 1 ointment topical for wound care, apply to L Buttocks and place 7x7 sacral foam bandage for protection of the wound. 8/19/25 RN wound care completed did not include zinc oxide application per order. In addition, most current updated care plan does address skin integrity with current interventions and goals. Corrected on site, care plan added. Patient 8: SN mentioning in all July visits “patient enjoying her therapy dog”. Per DON the hospice is supplying a therapy dog to patient at her visits. There is no order for a therapy dog. Corrected on site, order added. Patent 9: The SN documented 7/29/25 “Facility unit manager reports patient has a few diabetic ulcers to her feet. Small area to left lateral foot, left 2nd toe and right great toe. Applying betadine to the area and monitoring closely.” There is no evidence of an order to apply betadine or any orders for dressing changes to the diabetic ulcers. Patient 14: SN documented 7/30/25 finding a new wound to left ankle, and cleansed it with NS and applied a 4x4 foam dressing for protection. There is no order for wound care. On 8/4/25 the SN documented “L. Leg ulcers were assessed and changed, as dressing had come off due to saturation, multiple circular pinpoint openings to L. lateral shin r/t 2+ pitting edema, opening was a shallow ulcer measuring 1x1.5cm. Wounds were thoroughly cleansed and calcium alginate was cut to fit open areas and 6x6 cm foam dressing placed". There is no order for this wound care. 8/16/25 the SN documented “Pt assisted with wound dressing to BLE that was weeping, denies pain after dressing was done.” There is no order for wound care. The last SN visit documented was 8/6/25, there was a PRN visit completed 8/16/25 for wound care but, no routine SN visit the week of 8/10-8/16. There was no missed visit documentation or evidence of refusal. Orders are for SN once weekly on the POC.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The POC contains an order for “Cleanse wound site with NS and apply dry dressing.” The order does not state where the wound is, what to secure the dressing with, who is to provide wound care and a frequency. Corrected on site, wound care added.

Upon patient record review, 1 of 13 (Patient #1) 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 #1: Bereavement Risk Assessment not performed since the patient's admission.

Upon patient record review 4 of 9 (Patients #4,7,8,9) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: POC dated 7/24/21 CNA ordered 4x week- 1st visit 8/3 and only 3 visit that week, 8/3, 8/4, 8/5. Frequency not met week one. No evidence of missed visit or delay order found. Aide assignment included nail care and shave 1x week, Aide performed more frequently (2x wk) 8/4/22, 8/5, 8/9, 8/10, 8/11, 8/12. Patient #7: POC dated 2/17/22 CNA ordered 2xweek- no evidence of any visits, no evidence of missed visit or correction order. Frequency not followed. Patient #8: Aide assigned shampoo q bath, not performed 3/24/22. Patient #9: POC dated 4/27/21 CNA ordered 3xweek- 1st visit 4/28 without any additional visit that week. Freq not followed. No evidence of missed visit or correction order.