Every finding on record at Everclear Hospice & Palliative Care, Inc.

Upon patient record review, 11 of 14 (Patient # 1,2,3,4,5,6,9,10,11,12, and 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: There is no evidence of imminence of death documentation at SOC 6/20/25. Patient 2: There is no evidence of imminence of death documentation at SOC 7/28/25. Patient 3: There is no evidence of imminence of death documentation at SOC 3/20/25. Patient 4: There is no evidence of imminence of death documented at SOC 6/24/25. Patient 5: There is no evidence of imminence of death documented at SOC 9/2/25. Patient 6: There is no evidence of imminence of death documented at SOC 11/30/24. Patient 9: There is no evidence of imminence of death documented at SOC 11/18/23. Patient 10: There is no evidence of imminence of death documented at SOC 10/12/23. Patient 11: There is no evidence of imminence of death documented at SOC 09/17/24. Patient 12: There is no evidence of imminence of death documented at SOC 2/13/2025. Patient 14: There is no evidence of imminence of death documented at SOC 9/08/2023.

Upon patient record review, 2 of 14 (Patient # 3,4) 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 3: The medication list contains orders for Acetaminophen orders rectal suppositories 650 mg every 4 hours prn and Tylenol 500mg orally every 6 hours prn without a limit to not exceed 4 grams in 24 hours period. Corrected on Site with updated medication order with limit in 24 hour time period. Patient 4: The medication list 7/13/25 contains orders for Acetaminophen orders rectal suppositories 650 mg every 4 hours prn and Tylenol 650mg orally three times daily prn without a limit to not exceed 4grams in 24 hours period. Corrected on site with updated medication order with limit in 24 hour time period.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 9: There is evidence in the patient record upon election of benefits, patient chose to have attending physician follow care on hospice services. There is no evidence that POC, CTI or contact was made with attending physician of patient choice.

Upon patient record review, 2 of 14 (Patient # 3,4) 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 3: The updated POC 9/8/25 contains orders for Acetaminophen orders rectal suppositories 650 mg every 4 hours prn and Tylenol 500mg orally every 6 hours prn without a limit to not exceed 4 grams in 24 hours period. COS with updated POC Patient 4: The updated POC on 7/13/25 contains orders for Acetaminophen an order for rectal suppositories 650 mg every 4 hours prn and Tylenol 650mg orally three times daily prn without a limit to not exceed 4 grams in 24 hours period. COS with updated POC

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 9: There is evidence in the patient record upon election of benefits, patient chose to have attending physician follow care on hospice services. There is no evidence of collaboration with the attending physician since there was no signature to validate participation.

Upon patient record review, 2 of 14 (Patient # 3 and 4) 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 3: The updated POC on 9/8/25 following recertification contains no updated target dates for respiratory and GI problems/goals/interventions, outcomes remain dated for 7/17/25 for goals for respiratory and GI issues. COS with updated target dates on POC. Patient 4: The updated POC on 09/08/25 following recertification contains no updated target dates for goals for pain, sleep, nutrition and gastro-intestinal issues, outcomes remain dated for 8/22/25. COS with updated target dates on POC.

Upon personnel record review, 1 of 14 (Personnel # 5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel 5: Competency form includes multiple tasks for bathing and shampoo on one line on competency form instead of each task to be completed during observation with RN. There is not evidence that each task such as bed shampoo was observed separately during orientation observation prior to providing care.

Upon patient record review, 1 of 14 (Patient # 10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 10: The Initial Aide POC 10/12/23 contains orders for PRN Tasks for chair/bed options, encourage to offer fluids as needed and change briefs as needed.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 9: The initial CTI was signed and dated 01/19/2023 by Medical Director and initial SOC was on 11/18/23. The medical director documented the incorrect month on CTI.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 9: There is evidence in the patient record upon election of benefits, patient chose to have attending physician follow care on hospice services. There is no evidence that the initial CTI had verbal or written certification by the attending physician of patient choice.

Upon patient record review, 4 of 5 (Patient #1,2,3,& 4) the plan of care did not include the medical equipment of the patients which are necessary for the palliation and management of the terminal illness and related conditions. Patient #1 POC did not include the patient's cane which was identified in the nursing comprehensive assessment dated 4-08-2022. Patient #2 POC did not include the patient's walker & cane which was identified in the nursing comprehensive assessment dated 4-15-2022. Patient #3 POC did not include the patient's cane which was identified in the nursing comprehensive assessment dated 5-12-2022. Patient #4 POC did not include the patient's cane which was identified in the nursing comprehensive assessment dated 5-20-2022 and the front wheel walker which was observed during home visit on 6-03-2022.

Upon personnel record review, 1 of 1 applicable (Personnel #4) did not have evidence in the personnel file that a competency assessment was performed and that the following competencies were evaluated while the aide was performing the the tasks with a patient or a pseudo patient. Normal range of motion and positioning (42 CFR 418.76(b)(3)(x)) Appropriate and safe techniques in personal hygiene and grooming that include-(42 CFR 418.76(b)(3)(xi)) -Bed bath, -Sponge, tub, and shower bath -Shampoo, sink, tub, and bed -Nail and skin care -Oral hygiene -Toileting and elimination Personnel #4 did not have a validation of how the skills were evaluated, upon clarification another skills competency form was presented as evidence which still did not include that the required skills were observed while the aide was performing the tasks with a patient or a pseudo patient. All were marked as Verbal validation.