Every finding on record at Exclusive Palliative Hospice LLC

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. There is no evidence of a emergency communication plan for the agency.

Upon patient record review, 12 of 16 (Patient #1,2,3,4,6,7,11,12,13,14,15,16) 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 Patient has orders for oxygen concentrator, oxygen is not listed on the medication profile. IDG dated 1/17/25 states patient to start hydrocodone, oxygen is not listed on the medication profile. IDG dated 12/27/24 states to change pain meds to hydrocodone, however medications are not listed on the medication profile. Patient #2 On 9/24/24 states Oxygen is used at 2LPM PRN, however it is not listed on the medication profile. Patient #3 On 11/10/24 states Oxygen is used at 2LPM PRN, however it is not listed on the medication profile. Patient #4 On 8/18/24 states patient has an oxygen concentrator, however it is not listed on the medication profile. 8/18/24 physician notes the patient is receiving Lasix and Hydrocodone and are not listed on the medication profile. Patient #6 On 8/17/24 Patient has orders for oxygen concentrator, however it is not listed on the medication profile. Patient #7 On 5/22/24 states Oxygen is used at 2LPM PRN, however it is not listed on the medication profile. Patient #11 On 8/8/24 Patient has orders for oxygen concentrator, however it is not listed on the medication profile. Patient #12 On 8/9/24 Patient has orders for oxygen concentrator, however it is not listed on the medication profile. Patient #13 On 7/29/24 Patient has orders for oxygen concentrator and SN note dated 9/18/24 states oxygen used, however it is not listed on the medication profile. Patient #14 On 3/13/24 Patient has orders for oxygen concentrator, however it is not listed on the medication profile. Patient #15 On 2/12/24 POC states patient utilizes albuterol and oxygen PRN, however it is not listed on the medication profile. Patient #16 On 7/24/24 and 7/31/24 the POC states patient utilizes albuterol and oxygen PRN, however it is not listed on the medication profile.

Upon patient record review, 2 of 16 (Patient #6,13) 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 #6 No initial bereavement assessment completed at start of care. Patient #13 No initial bereavement assessment completed at start of care.

Upon patient record review, 1 of 16 (Patient #12) 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 #12 On 10/25/24 SN documents the patient has stage 2 and 3 wounds, however no evidence of wound care orders or assessment of wounds

Upon patient record review, 13 of 16 (Patient #1,2,3,4,6,7,10,11,12,13,14,15,16) 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 Patient has orders for oxygen concentrator, however no orders present for oxygen on the plan of care. IDG dated 1/17/25 states patient to start hydrocodone, however no orders present for the medication. IDG dated 12/27/24 states to change pain meds to hydrocodone, however no orders present for the medication. Patient #2 On 9/24/24 states Oxygen is used at 2LPM PRN, no orders present for oxygen therapy on the plan of care. Patient #3 On 11/10/24 states Oxygen is used at 2LPM PRN, no orders present for oxygen therapy on the plan of care. Patient #4 On 8/18/24 states patient has an oxygen concentrator, but no orders for oxygen therapy administration. The 8/18/24 physician notes the patient is receiving Lasix and Hydrocodone, however there are no orders for the medications. Patient #6 On 8/17/24 Patient has orders for oxygen concentrator, but no orders for oxygen therapy administration on the plan of care. Patient #7 On 5/22/24 states Oxygen is used at 2LPM PRN, no orders present for oxygen therapy on the plan of care. Patient #10 On 4/4/24 has orders present for Diclofenac, however no indication of specific location to apply. Patient #11 On 8/8/24 Patient has orders for oxygen concentrator, no orders present for oxygen therapy on the plan of care. Patient #12 On 8/9/24 Patient has orders for oxygen concentrator, no orders present for oxygen therapy on the plan of care. On 10/25/24 SN documents the patient has stage 2 and 3 wounds, however no evidence of wound care orders. Patient #13 On 7/29/24 Patient has orders for oxygen concentrator and SN note dated 9/18/24 states oxygen used, but no orders for oxygen therapy administration on the plan of care. Patient #14 On 3/13/24 Patient has orders for oxygen concentrator, no orders present for oxygen therapy on the plan of care. Patient #15 On 2/12/24 POC states patient utilizes albuterol and oxygen PRN, no orders present for albuterol and oxygen therapy on the plan of care. Patient #16 On 7/24/24 and 7/31/24 POC states patient utilizes albuterol and oxygen PRN, no orders present for oxygen therapy on the plan of care.

Upon patient record review, 2 of 16 (Patient #1,2) 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 #1 IDG meetings completed 11/22/24 and was due by 12/6/24 and the IDG was not completed until 12/13/24. Patient #2 IDG meetings completed 9/27/24 and was due by 10/4/24 and the IDG was not completed until 10/11/24.

Upon patient record review, 3 of 16 (Patient #3,4,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 On 12/18/24 SN documented a missed visit, no reason documented of reason for missed visit, no orders present for missed visit and/or change in frequency. Patient #4 On 8/18/24 SN visit frequency is ordered 1x/week and visits were made on 8/19/24 and 8/22/24 Patient #12 On 8/10/24 MSW frequency is ordered 1x/month but no visits were made in September 2024

Upon patient record review, 4 of 16 (Patient #1,4,5,6) 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 Aide care plan was blank for time period dated 1/7/25 with no tasks selected for the aide to perform for Toileting, Dressing, Diet, Bathing, Hair care, Mouth Care, Skin, Precautions. Pt was dependent on care according to documentation. Patient #4 Aide care plan was blank for time period dated 8/18/24 with no tasks selected for the aide to perform for Toileting, Urinary, Bowel, Dressing, Diet, Bathing, Mouth care, hair care or skin care. Pt was dependent on care according to documentation. Patient #5 Aide care plan was blank dated 3/5/24 with no tasks selected for Dressing, Bathing, skin care, ambulation/mobility or incontinence care. Pt was dependent on care according to documentation. Patient #6 Aide care plan dated 8/17/24 has both walker and wheelchair task selected for mobility, aide cannot choose which device to use.

Upon patient record review 1 of 16 (Patient #1) 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 Aide visits completed on 1/8/25, 1/10/25, 1/14/25 have no documentation of tasks completed per aide care plan

Upon patient record review, 6 of 16 (Patient #2,3,6,10,12,13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2 SN completed an aide supervisory visit on 1/8/24, 1/3/24, 12/24/24, 12/17/24, 12/10/24 and 12/3/24 however there is no aide visits ordered or completed in the patient record. Patient #3 SN completed aide supervisory visits on 11/20/24, 11/27/24 and 12/4/24 however there is no aide visits ordered or completed in the patient record. Patient #6 SN states on 8/19/24 that she checked foley and g-tube, however there is no evidence of patient having either. Patient #10 Consents on 4/4/24 were signed by K. M. however there is no evidence or paperwork identifying the relationship or POA in place. Patient #12 POC IDG Meeting dated 11/8/24 has not been signed by any disciplines Patient #13 SN states on 9/23/24 that she checked foley and g-tube, however there is no evidence of patient having either.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.