Every finding on record at Curae Hospice Care, Inc.

Upon patient record review, 3 of 16 (Patient # 4, 5, and 6) 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 4: The medication profile includes an order for Lidocaine patch on 2/6/25 to apply to affected area as needed without specification of where patch should be applied. Patient 5: The medication profile includes an order for Lidocaine patch on 7/4/25 to apply to affected area once daily without specification of where patch should be applied. Patient 6: The medication profile includes an order for Lidocaine patch on 3/6/25 to apply to affected area once daily without specification of where patch should be applied.

Upon patient record review, 2 of 16 (Patient # 1, 5) 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: There is no evidence of an initial bereavement assessment completed within the initial 5 days of SOC 1/16/26. Patient 5: There is no evidence of an initial bereavement assessment completed within the initial 5 days of SOC 7/4/25.

Upon patient record review, 3 of 16 (Patient #4,7,8) 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 4: The POC on 1/31/25 at SOC contains incomplete interventions listing "oxygen at liters/min via nasal cannula or mask for hours of use." There is no evidence that patient is on oxygen. Patient 7: The POC on 2/6/25 at SOC contains incomplete interventions listing oxygen at liters/min via nasal cannula or mask for hours of use." There is no evidence that patient is on oxygen. Patient 8: The POC on 1/30/25 at SOC contains incomplete interventions for "oxygen at liters/min via nasal cannula or mask for hours of use."

Upon patient record review, 3 of 16 (Patient # 4, 5, 6) 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 4: The POC on 2/6/25 includes an order for Lidocaine patch without specification of where patch should be applied. Patient 5: The POC on 7/4/25 includes an order for Lidocaine patch without specification of where patch should be applied. Patient 6: The POC on 3/6/25 includes an order for Lidocaine patch without specification of where patch should be applied.

Upon personnel record review, 1 of 11 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1: Administrator does not have evidence of position qualifications per job description of 3-5 years experience in health care management. There is evidence he was hired as office manager on 09/01/23 and assumed role of Administrator 12/10/24 when RN education was completed. A resume is presented to surveyor that includes past experience as RN DPCS at another agency 6/1/25-present and DPCS 1/1/25-present. He graduated with AD in nursing in Sept 2024 and Bachelor of Science in Biology in 6/2022. He served as an office manager for Triplet Home health 6/2019-10/2024 prior to earning his RN degree.

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) 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 initial spiritual assessment indicated presence of anxiety and fear but did not contain problems, goals and interventions related to anxiety and fear. Patient #2, #3 initial spiritual assessment indicated presence of anxiety but did not contain problems, goals and interventions related to anxiety. Patient #4 initial spiritual assessment indicated presence of denial of reality and pain but did not contain problems, goals and interventions related to denial of reality and pain.

Upon patient record review, 1 of 5 (Patient #3) 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 the patient record on 1/26/23 by RN evidenced the use of wheel chair but no wheel chair in DME order. Corrected on site.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.