Every finding on record at Envoy Hospice, LLC

Upon patient record review, 3 of 19 (Patient #1,#2,#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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1:The medication profile includes an entries of Acetaminophen rectal suppository 650mg q 6 hours, Acetaminophen 500 mg po q 6 and Acetaminophen with codeine 300/30 q 4 hours PRN. The entries do not include a maximum dose of 4000mg daily. The medication profile includes an entry for MiraLAX 17 gm q night for constipation. There is no evidence that the entry includes the type and amount of diluent required for administration of the medication. COS Patient 2:The medication profile includes an entries of Acetaminophen Tylenol 325 mg q 4 hours PRN and Tylenol arthritis 650 q8 PRN. The entries do not include a maximum dose of 4000mg daily. COS Patient 6:The medication profile includes an entries of Tylenol with Codeine #4 300/60mg q 6 hours PRN and Acetaminophen Suppository 650 q 6 hours PRN. The entries do not include a maximum dose of 4000mg daily. COS

Upon patient record review, 2 of 19 (Patient #8,#12) 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 8:The medical record contains nursing documentation on admission and on-going of "skin tumors all over body". There is no evidence that the plan of care includes problems, goals and interventions related to skin or integumentary. Patient 12:The medical record contains nursing documentation on admission and on-going nutrition issues inlcuding altered diet and risk of aspiration. There is no evidence that the plan of care includes problems, goals and interventions to manage altered nutrition and risk of aspiration.

Upon patient record review, 3 of 19 (Patient #1,#2,#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 1:The plan of care includes orders of Acetaminophen rectal suppository 650mg q 6 hours, Acetaminophen 500 mg po q 6 and Acetaminophen with codeine 300/30 q 4 hours PRN. There is no evidence that the orders include a maximum dose of 4000mg daily. COS Patient 2:The medication profile includes an entries of Acetaminophen Tylenol 325 mg q 4 hours PRN and Tylenol arthritis 650 q8 PRN. There is no evidence that the orders include a maximum dose of 4000mg daily. COS Patient 6:The medication profile includes an entries of Tylenol with Codeine #4 300/60mg q 6 hours PRN and Acetaminophen Suppository 650 q 6 hours PRN. There is no evidence that the orders include a maximum dose of 4000mg daily. The plan of care includes an order for MiraLAX 17 gm q night for constipation. There is no evidence that the order includes the type and amount of diluent required for administration of the medication. COSCOS

Upon patient record review, 1 of 19 (Patient #1) 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 1: The medical record includes nursing documentation that the patient equipment and supply needs include a hospital bed, Hoyer lift, trapeze bar and Bi-Pap equipment and supplies. There is no evidence that a hospital bed, Hoyer lift, trapeze bar and Bi-Pap equipment and supplies are included on the plan of care.

Upon patient record review 3 of 19 (Patient #1,#9,#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 1:The aide plan of care includes the tasks of bed bath, linen change and shampoo hair assigned Monday, Wednesday and Friday. The aide documentation notes all tasks were completed on 4/16/24 and 4/30/24, both are Tuesdays. Patient 9:The aide plan of care includes the tasks of shower and shave ordered every other day with aide frequency of 5x/week. Aide documentation for the week 4/1/24 notes that the task of shave was completed only on Monday and a shower was Monday, Tuesday, Wednesday Thursday and Friday. Patient 13:The aide plan of care includes the task of shampoo hair assigned Monday, Wednesday and Friday. Aide documentation notes that the task was completed on Tuesday 4/16/24 and Thursday 4/18/24.