Every finding on record at Celtic Hospice & Palliative Care Services, LLC

Upon patient record review, 4 of 27 (Patient #9, 18, 21, 24) 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 #9 - Order written on 06/23/25 and 06/30/25 to recheck INR did not contain how to obtain - finger stick or venipuncture. Patient #18 - Recertification POC order "change #16 -10cc monthly and as needed - no modifier for as needed. May irrigate with NS 30cc as needed - no frequency. Patient #21 - Initial POC contained #16 -10cc Foley catheter change as needed - no modifier for as needed. Order on 05/28/25 "keep DTI protected with foam dressing, change 2 x wk - no wound site noted. New wound order coccyx 06/20/25 did not contain frequency. Patient #24 - Initial POC order to "remove sutures, apply steri strips and cover with ABD" no date when sutures should be removed.

Upon patient record review, 1 of 27 (Patient #17) 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 #17 - Patient has a CPAP not on POC.

Upon patient record review, 1 of 27 (Patient #11) 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 #11 - The plan of care 06/11/25, has SC included, patient is not receiving SC services - patient declined this discipline.

Upon patient record review, 1 of 27 (Patient #24) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #24 - SN visit note 05/20/25 "14 staples removed - cleaned site with soap and water" order was to "clean with wound cleanser, apply steri strips and ABD".

Upon patient record review 1 of 27 (Patient #23) 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 #23 - Aide care plan has task bed bath every visit but aide gave shower on 06/04/25, 06/09/25 and 06/11/25.

Upon patient record review 1 of 27 (Patient #23) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #23 - Aide documented on visit note 06/16/25 "sister brought patient THS gummies" no notification to case manager noted.

Upon patient record review, 2 of 27 (Patient #9, 24) 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 #9 - SN visit note 06/23/25, INR 1.2 - no documentation of how obtained or site. Patient #24 - SN visit note 05/23/25 documentation "Foley catheter patent with straw colored urine and coccyx stage 2 managed at this time" patient does not have a Foley catheter or wound. Aide supervisory visit completed but patient not receiving aide services. When reviewed with nurse she had documented on wrong chart. Corrections made to both charts.

Upon patient record review, 1 of 27 (Patient #9) 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 #9 - Order for INR on 06/21/25 and 06/23/25 there is no documented evidence of which provider is to perform INR. COS, Care Plan updated.

Upon patient record review, 1 of 20 (Patient #1) 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 receiving O2 at 3-4L/M but not on medication profile.

Upon patient record review, 3 of 20 (Patient #1, 7, 16) 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 - Patient receiving O2 at 3-4L/M but not on plan of care. Patient #7 - POC 05/31/2022 contained order to flush port monthly with 10cc NS - did not contain procedure details or huber needle size. Patient #16 - POC 04/23/2022 - SN to insert foley catheter - did not contain catheter size.

Upon patient record review, 6 of 15 applicable (Patient # 7, 10, 11, 12, 17, 20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 - SN visit note "flushed catheter with 30 cc of SS" no order on POC to flush foley catheter. Patient #10 - SN visit note 05/12/2022 and 06/13/2022 foley catheter changed but no order on POC dated 05/09/2022. Patient #11- SN visit note 06/09/2022 "hydrocolloid dressing applied to wound" no order for hydrocolloid dressing on POC 05/17/2022. Patient #12 - SN visit note 06/06/2022 and 06/10/2022 "bilateral legs seeping fluid - wrapped with gauze and secured with kerlix" No order on POC dated 06/02/2022. Patient #17 - SC order 02/25/2022 "add 2 F2F visits this month" no visit made 02/25/2022 thru 02/28/2022. Patient #20 - SN visit note 06/02/2022 "applied duoderm to small area of DTI - nickle size" No order on POC dated 04/27/2022.

Upon patient record review 2 of 17 applicable (Patient #5, 8) 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. Patient #5 - CNA visit frequency 2wk3 effective 06/26/2022 - only 1 missed visit documented week 1.

Upon patient record review, 3 of 5 applicable (Patient #3, 8, 19) 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 #3 - POC dated 04/06/2022 did not specify which provider (nursing facility or hospice) is responsible for performing the wound care or foley catheter. Patient #8 - POC dated 05/11/2022 did not specify which provider (nursing facility or hospice) is responsible for performing the wound care. Patient #19 - POC dated 04/09/2022 did not specify which provider (nursing facility or hospice) is responsible for performing the wound care.