Every finding on record at Excellent Palliative and Hospice Care Inc

Upon patient record review, 2 of 14 (Patient #9, 13) 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 #9 - Medication profile contained Tums and Salonpas Pain Patch but did not contain dosage or frequency or PRN modifier. Patient #13 - Medication profile contained Humalog 10 -14 units subcutaneous daily 15 minutes before meals, but patient taking 10 - 14 units subcutaneous 3 times a day 15 minutes before meals. Sliding scale written as 10 units if 25% of meal, 12 units if 50% of meal and 14 units for 75% of meals.

Upon patient record review, 2 of 14 (Patient #10, 14) 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 #10 - POC 02/23/25 SN daily for continuous care did not specify the SN visit times and hours to be provided. Patient #14 - POC 02/13/25 SN daily for continuous care did not specify the SN visit times and hours to be provided.

Upon patient record review, 1 of 14 (Patient #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 #13 - POC contained Humalog 10 -14 units subcutaneous daily 15 minutes before meals, but patient taking 10 - 14 units subcutaneous 3 times a day 15 minutes before meals. Sliding scale written as 10 units if 25% of meal, 12 units if 50% of meal and 14 units for 75% of meals.

Upon client record review, 5 of 14 (Patient #6,7,9,8,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 - POC 08/22/25 LVN visit frequency 1 x week but LVN saw patient 2 x week the week of 08/24,25, 08/31/25 and 09/07/25. Patient #7 - POC 07/15/25 SC visit frequency every recertification but no SC visit made prior to recertification. POC 07/15/25 MSW made visit 07/16/25 but no order for the visit. Patient #9 - POC 08/14/25 LVN visit frequency 1 x week but LVN made 2 visit per week the week of 08/16/25 and 08/24/25. Patient #8 - POC 08/03/25 LVN 1 x week no visit made week of 08/03/25. Patient #11 - POC 04/15/25 RN visit frequency every 14 days RN made visit 04/23/25 then not again until 05/14/25.

Upon patient record review 3 of 14 (Patient #5, 6, 11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #5 - The record indicated that an aide supervisory visit was conducted on 7/28/25 and not again until 9/07/25. Patient #6 - The record indicated that an aide supervisory visit was conducted on 7/17/25 and not again until 8/01/25 and on 8/14/25 and not again until 8/29/25. Patient #11 - The record indicated that an aide supervisory visit was conducted on 4/23/25 and not again until 5/14/25.

Upon patient record review, 2 of 5 (Patient #2 and 3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: RN order dated at SOC 4/11/2022 is RN sup visit and comprehensive eval. every 14 days. For visits of 5/23/2022, and 6/6/2022, the nurses note is timed for 0900-0945 each day and dated but contains no information and the assessment is blank. There is no evidence of a RN visit or comprehensive assessment after 5/8/2022. Patient 3: RN order dated at SOC 3/21/2022 is RN sup. visit and comprehensive eval. every 14 days. For visits 5/16/2022, 5/30/2022, and 6/13/2022, there are dated and timed notes all 0900-0945, but contains no information and the assessment is blank. There is no evidence of a RN visit or comprehensive assessment after 5/2/2022.

Upon client record review, 4 of 5 (Patient #1, 2, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1, 2, 4: Spiritual Care and Social work made visits via telehealth. There is no evidence of an order for Telehealth visits. Patient 3: Social work made a visit via telehealth. There is no evidence of an order for Telehealth visits. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: SN placed bag on dirty arm of recliner. Policy included bag to be placed on clean dry surface. There was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions.

Upon personnel record review, 1 of 1 applicable records (Personnel #6) did not have evidence in the personnel file that the 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.) Personnel 6: All skills were verbally assessed on hire/Start of patient care. There was no evidence the competency assessment was performed by the aide with a patient.

Upon patient record review, 1 of 5 records (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: On SOC RN assessment, the documentation includes pt. is bedbound, maximum transfer, impaired balance, weakness and high fall risk. There is no evidence of fall precautions on the HHA POC. Corrected on site.

Upon patient record review 1 of 5 records (Patient #4) 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 4: HHA frequency on SOC 3/26/2022 3 x week. There is no evidence of HHA visits or missed visits for week of 3/27/2022.

Upon patient record review, 2 of 5 (Patient #3 and 4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 3: SOC 3/31/2022 into BP 3. There is no evidence of a written cert for SOC. There is a Written cert for BP4. Patient 4: SOC 3/26/2022 into BP 3. There is no evidence of a written cert for SOC. There is a written cert. for BP 4.