Every finding on record at Compassionate Care Hospice of the Midwest, LLC

Upon patient record review, 1 of 19 (Patient #11) 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 11: The medication profile includes an entry on 11/24/23 for oxygen 2 liters per minute. There is no evidence on the profile of a route for administration of oxygen.

Upon patient record review, 1 of 19 (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 medical record includes nursing documentation of a left lower leg wound. The order obtained from the physician on 3/29/24 included daily care using a non adherent dressing and RN to assess and measure weekly. There is no evidence of wound measurements from 3/29/24 through 4/10/24.

Upon patient record review, 2 of 19 (Patient #11,13) 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 11:The plan of care includes an order written on 11/24/23 for oxygen 2 liters per minute. There is no evidence that the order includes a route of administration for the oxygen. Patient 13:The plan of care includes an order written on 3/24/24 to cleanse wound with wound cleanser, apply collagen powder and cover with 4x4 daily. There is no evidence that the order includes the location of the wound and who is to provide care.

Upon patient record review 4 of 19 (Patient #1,#2,#6,#10) 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 1:The hospice aide plan of care includes assigned tasks of tub bath weekly on Wednesday and nail care on Monday. Documentation by the aide notes that both the tub bath and nail care was provided on 3/2/24 and that nail care was provided all for all visits from 2/26/24 through 3/9/24. Patient 2:The hospice aide plan of care includes assigned tasks of weight and nail care weekly on Monday. Documentation by the aide notes nail care was completed on Tuesday 4/1/24 and weight was obtained on Friday 4/5/24. Patient 6:The hospice aide plan of care includes assigned tasks of patient shave and weight to be completed weekly on Monday and nail care to be provided weekly on Wednesday. Aide visits were provided only on Thursday, Saturday and Sunday from 3/1/24 to present. Documentation by the aide on 3/24/24 (Sunday) and 4/2/24 (Tuesday) indicates that nail care was provided and there is no documentation to support that task of patient shave and weight has been provided since 3/1/24. Patient 10:The hospice aide plan of care incudes the task of clean nails to be completed weekly on Monday. Documentation by the aide noted that nail care was completed on the following Friday visits: 3/1/24, 3/29/24 and 4/5/24.