Every finding on record at Community Professional Hospice Care, LLC

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 6: The plan of care effective 01/22/26 recorded the following frequency, "RN: 1 -SFV (1 symptom) visit." There was no supplemental MD order found to correct this to include a detailed scope and frequency of services necessary to meet patient/family needs.

Upon client record review, 3 of 14 (Patient #5, 6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The plan of care effective 01/22/26 recorded skilled nurse visit frequency as, "LVN 1 per week" and "RN 1 per 2 week." The medical record revealed the LVN completed a visit on 02/04/26 and 02/05/26. The LVN documented the 02/05/26 visit as, "PRN" related to a fall. There was no evidence of an MD order authorizing an additional nursing visit on 02/05/26 found in the medical record. The Plan of Care update completed on 02/05/26 continued the LVN frequency of 1 per week. Patient 6: The plan of care effective 01/22/26 recorded the following frequency, "RN: 1 -SFV (1 symptom) visit." The medical record contained documented RN visits weekly. There was no supplemental MD order found to correct this nor were any subsequent plan of care updates found to correct the nurse frequency. Patient 10: The plan of care effective 02/21/26 recorded the following frequency, "RN: 2 per week." The medical record revealed documentation of only one RN visit the weeks of 02/22/26 and 03/01/26. There were no documented RN visits found the week of 03/08/26. There was no recorded evidence found of patient or caregiver refusal of visits. Further, there was no supplemental MD order found to change the frequency of RN visits. The plan of care update dated 03/05/26 contained the frequency of, "RN: 2 per week."

Upon patient record review 2 of 14 (Patient #5, 13) 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 5: The aide instructions effective 10/10/25 indicated vital signs should be taken at each aide visit. There was no documented evidence of vital signs being taken and recorded on 02/20/26. Patient 13: The aide instructions effective 09/05/25 indicated vital signs should be taken at each aide visit. There was no documented evidence of vital signs being taken and recorded on 11/27/25, 12/11/25, and 01/01/26.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #4, #6, #8 and #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 medication profile includes "Imodium A-D 2mg cap 2 caps on day 1, then 1 cap after each loose BM" with no specific frequency and no daily dosage limit, "Acetaminophen 500mg tab 1 tab orally every 4 hours prn pain" with no daily dosage limit. Patient #2 medication profile includes "Tylenol 500mg tab 1 tab orally every 8 hours prn mild to moderate pain" with no daily dosage limit. Patient #3 medication profile includes "Tylenol 650mg ER cap 1 cap orally every 8 hours prn pain" with no daily dosage limit. Patient #4 medication profile includes "Acetaminophen 325mg tab 1-tab po every 6 hours for mild pain" with no daily dosage limit. Patient #6 medication profile includes "Acetaminophen 500mg cap 1 cap every 6 hours prn pain" with no daily dosage limit. Patient #8 medication profile includes "Acetaminophen 500mg cap 1 cap every 8 hours prn pain" with no daily dosage limit. Patient #10 medication profile includes "Halobetasol Propionate 0.05% topical cream, apply thin layer to affected areas once daily as needed" with no indicator and no specific location identified.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #4, #6, #8 and #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 plan of care includes "Imodium A-D 2mg cap 2 caps on day 1, then 1 cap after each loose BM" with no specific frequency and no daily dosage limit, "Acetaminophen 500mg tab 1 tab orally every 4 hours prn pain" with no daily dosage limit. Patient #2 plan of care includes "Tylenol 500mg tab 1 tab orally every 8 hours prn mild to moderate pain" with no daily dosage limit. Patient #3 plan of care includes "Tylenol 650mg ER cap 1 cap orally every 8 hours prn pain" with no daily dosage limit. Patient #4 plan of care includes "Acetaminophen 325mg tab 1-tab po every 6 hours for mild pain" with no daily dosage limit. Patient #6 plan of care includes "Acetaminophen 500mg cap 1 cap every 6 hours prn pain" with no daily dosage limit. Patient #8 plan of care includes "Acetaminophen 500mg cap 1 cap every 8 hours prn pain" with no daily dosage limit. Patient #10 plan of care includes "Halobetasol Propionate 0.05% topical cream, apply thin layer to affected areas once daily as needed" with no indicator and no specific location identified.