Every finding on record at Family Hospice, Ltd.

Upon patient record review, 5 of 19 (Patient #1, #2, #3, #4, #12) 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 hospice medication profile indicates this patient is on continuous oxygen. However, there is no evidence of continuous oxygen on the facility MAR. Patient#2: The hospice medication profile states patient is taking lorazepam 0.5mg 1 every 4 hours PRN anxiety and restlessness, geri-tussin 100mg/5ml every 6 hours PRN cough, Ipratropium 0.5 albuterol 3mg nebulizer solution, oxygen 1-3 lpm nasal cannula PRN SOB, and benzonatate 100mg 1 every 6 hour PRN for cough. There is no evidence of these medication on the facility MAR. Patient#3: The hospice medication profile indicates patient is taking hydromorphone 1 tice a day. It also indicates patient has an order for hydromorphone 1 every 4 hours PRN for breakthrough pain. In the home the only instruction on the hydromorphone if for 1 every 4 hours PRN. The order for the scheduled hydromorphone to help control pain was dated 1/16/26. The bottle in the home was filled on 02/17/26. Patient#4: During home visit, it was noted the facility MAR contained zinc oxide 10% apply three times a day and hydrocortisone 1% apply every 12 hours PRN itching. There is no evidence of these on the hospice medication profile. Additionally, the hospice medication profile list acetaminophen 325mg take 2 every 6 hours PRN. There is no evidence of this medication on the facility MAR. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. However, on 1/22/26 on 1/22/26 the nurse documents the patient was on 10L when she arrived for her afternoon visit. She educated the caregiver and moved patient down to 6Lpm. On 1/28/26 the nurse documents that the patient reported being comfortable at 2 lpm. There is no evidence of oxygen ordered at these levels for daytime or PRN usage on the medication profile.

Upon patient record review, 1 of 19 (Patient #2) 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#2: The aide plan of care list the patient have vision as a functional limitation and requires visual precautions. There is no evidence of goals and interventions related to these issues on the plan of care.

Upon patient record review, 2 of 19 (Patient #4, #12) 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: During home visit, it was noted the facility MAR contained zinc oxide 10% apply three times a day and hydrocortisone 1% apply every 12 hours PRN itching. There is no evidence of an order for these in the hospice medical record. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. On 1/28/26 the nurse documents that the patient reported being comfortable at 2 lpm. There is no evidence of an order for oxygen ordered at this level for daytime or PRN usage in the hospice medical record.

Upon patient record review, 3 of 19 (Patient #3, #5, #14) 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 nurse documents for IDG 1/22/26 that suction was delivered due to patient issues with increased mucous production. There is no evidence of an order for suction machine include in the plan of care. Patient#5:The record indicates the patient has wound care and pressure relieving boots. There is no evidence of an order including these items on the plan of care. Patient#14:The record indicates wound care supplies are listed on the plan of care. There is no evidence in the record indicating the patient requires wound care supplies.

Upon patient record review, 3 of 19 (Patient #1, #5, #7) 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#1:The patient currently takes medication for insomnia. The nurse documents on 1/12/26 that the patient has continued issues with insomnia. The doctor has an order on 2/22/26 to add insomnia as a diagnosis. There is no evidence of problems with goals and interventions related to insomnia on the plan of care. Patient#5:The record indicates the nurse documented on visit 2/2/26 that patient received pressure relieving boots. She also documents that she told the spouse she would be educating the facility staff on appropriate use of this item. There is no evidence of goals of interventions related to this on the plan of care. Patient#7: The record indicates MSW services were discontinued on 1/3/26. However, the MSW goals and interventions are still active on the plan of care. The record also indicates that from 1/1/26 till 2/3/26 the patient had a nephrostomy tube. There is no evidence of problems, goals, or interventions related to the nephrostomy tube care.

Upon client record review, 3 of 19 (Patient #3, #9, #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: The record indicates the frequency order for MSW states effective 2/1/26. However, there is an MSW visit documented on 1/16/26. There is no evidence of a frequency order for this visit. Patient#9: The record indicates the frequency for skilled nurse is ordered for 1 time per week. There is no evidence of a documented visit or a missed visit for the week of 2/8/26. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. However, on 1/22/26 the nurse documents the patient was on 10L when she arrived for her afternoon visit. She educated the caregiver and moved patient down to 6Lpm, there was no evidence of an order for this liter flow.

Upon patient record review 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#7:During record review, the POC indicated chaplain services were discontinued 2/10/26. IDG on 1/22/26 written by female chaplain indicates that chaplain visits are to be moved to a male chaplain per patient preference. The female chaplain documents speaking to the male chaplain on 1/20/26 about this. She then documents that chaplain visits should be removed from this chaplain. There is a doctor order stating to discontinue all chaplain visits. There is no evidence that chaplain services have continued with the male chaplain.

Upon patient client record review, 2 of 19 (Patient #7, #16) 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#7: During record review it was noted that the plan of care indicates patient is a full code. However, the MSW documents during IDG 1/8/26 and on visit 1/2/26 that patient is a DNR. There is no evidence of a DNR in the patient record. Conflicting information. Patient#16: The discharge summary states "discharge to home or self-care;live discharge out of service area- No GIP contract (symptom management reason related to prognosis)." It is unknown if the patient was admitted to hospital or to the hospice GIP unit at hospital.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon patient record review 1 of 13 records (Patient #9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #9: The patient was admitted on 1/11/23. The record indicated that the spiritual assessment was completed on 1/18/23.

Upon patient record review 2 of 13 records (Patient #1,#8) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1,#8: There was not evidence of a spiritual assessment.

Upon patient record review, 7 of 13 records (Patient #1,#2,#6,#7,#10,#11,#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 #1:The medication profile contained atropine eye drops 1-2 drops hourly under the tongue and atropine eye drops 2-4 drops hourly SL. The ordered medication was a duplicate with the only difference being the number of drops. In addition, there was a duplicate listing of Ipratropium 0.5-Albuterol 3mg/3ml q6h prn. Corrected on site. Patient #2: The medication profile contained Acetaminophen 325mg, 2 tabs 3x daily prn pain or fever. There was not evidence of parameters for the fever. Corrected on site. In addition, the medication profile contained Bactrim DS 800 mg-160, 1 daily for 10 days, ordered on 3/1/23. This medication remained on the medication profile. Corrected on site. Patient #6: The medication profile contained Acetaminophen 500mg, 2 tabs q6h prn prn pain or fever. There was not evidence of parameters for the fever. Corrected on site. Patient #7: The medication profile contained a duplication of Guaifenesin; Guaifenesin 400mg 2x/day and Guaifenesin 400mg, 1 tab 3x/daily prn. Corrected on site. Patient #10: The medication profile contained Polyethylene Glycol 3350 17 GM/dose oral powder daily prn for constipation. There was not evidence of a diluent. Corrected on site. Patient #11: The medication profile contained Diclofenac 1%, apply 2 inches to skin as needed for pain. There was not evidence of a frequency or a specific location. In addition, Acetaminophen 650mg rectal supp, 1 q6h prn pain or fever and Acetaminophen Extra Strength 500mg, 2 tabs q6h prn, pain of fever, There was not evidence of a maximum allowable dose for 24h or a parameter for the fever. Patient #13: The medication profile contained Tylenol 325mg, 1-2 tabsq6h prn pain or fever. There was not evidence of a parameter for the fever.

Upon patient record review, 1 of 13 records (Patient #4) 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 #4: The patient was admitted on 2/13/23. The record indicated that the bereavement assessment was not completed until 2/20/23.

Upon patient record review, 1 of 13 records (Patient #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects 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 #12: The patient was admitted with a diagnosis of COPD. Nurse documentation at the IDT meetings indicate that there is respiratory education related to knowledge deficit, respiratory distress and a chest x-ray confirmed pneumonia. There was not evidence that the plan of care reflects patient/family goals and interventions based on the patient's respiratory problems.

Upon patient record review, 1 of 13 records (Patient #5) did not have evidence the plan of care 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 Patient #5: The patient went to respite on 3/8/23 for 5 days. The order description indicated to increase to daily visits by 1 discipline. The order dated 3/8/23 indicated 'SN effective 3/5/23 3w2, 2w3,1w1.' Visits were conducted on 3/8/23, 3/9/23, 3/10/23, and 3/11/23. There was not evidence of a clear and detailed order description.

Upon patient record review, 7 of 13 records (Patient #1,#2,#6,#7,#10,#11,#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 #1:The record contained orders for atropine eye drops 1-2 drops hourly under the tongue and atropine eye drops 2-4 drops hourly SL. The ordered medication was a duplicate with the only difference being the number of drops. In addition, there was a duplicate listing of Ipratropium 0.5-Albuterol 3mg/3ml q6h prn. Corrected on site. Patient #2: The record contained an order for Acetaminophen 325 mg, 2 tabs 3x daily prn pain or fever. There was not evidence of parameters for the fever. Corrected on site. Patient #6: The record contained an order for Acetaminophen 500 mg, 2 tabs q6h prn prn pain or fever. There was not evidence of parameters for the fever. Corrected on site. Patient #7: The record contained an order for Guaifenesin; Guaifenesin 400mg 2x/day and Guaifenesin 400mg, 1 tab 3x/daily prn. Corrected on site. Patient #10: The record contained an order for Polyethylene Glycol3350 17 GM/dose oral powder daily prn for constipation. There was not evidence of a diluent. Corrected on site. Patient #11: The record contained an order for Diclofenac 1%, apply 2 inches to skin as needed for pain. There was not evidence of a frequency or a specific location. In addition, Acetaminophen 650mg rectal supp, 1 q6h prn pain or fever and Acetaminophen Extra Strength 500mg, 2 tabs q6h prn, pain of fever, There was not evidence of a maximum allowable dose for 24h or a parameter for the fever. Patient #13: The record contained an order for Tylenol 325mg, 1-2 tabsq6h prn pain or fever. There was not evidence of a parameter for the fever.

Upon client record review, 3 of 13 records (Patient #5,#8,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The volunteer frequency, dated 2/17/23 was 1x/week. The record indicated only 1 visit/contact on 2/22/23. Corrected on site. Patient #8: The visit frequency for the social worker for the benefit period of 1/11/23-3/11/23 and 3/12/23-5/10/23 were both 2m2,1m1. The record indicated that no visits were made in January, 2 in February and none in March. Patient #9:The volunteer frequency dated 3/1/23 was for a 1 time visit. The record indicated that visits were conducted on 3/7/23 and 3/15/23. In addition, the visit frequency for the spiritual care counselor was for an evaluation then 1 every 2m2, 1m1. The record indicated that the evaluation was conducted on 1/18/23 and routine visits were conducted on 2/16/23 and 3/6/23. Also, the visit frequency for the social worker was for 1 every 2m2, 1m1. The record indicated that an evaluation was conducted on 1/11/23 and routine visits were conducted on 2/21/23 and 3/16/23. Corrected on site.

Upon patient client record review, 2 of 13 records (Patient #2 and 3) did not have evidence that each patient record contains Advance Directives. Patient #2: The record indicated that the patient had an Advance Directive. There was not evidence that this was a part of the medical record. Corrected on site. Patient #3: The social work note dated 1/23/23 indicated that the patient was a full code. The initial plan of care and each update indicated that the patient was a DNR. A social work note dated 2/3/23 indicated that the patient completed the Advance Directive (OOH-DNR). The DNR could not be located. It could not be determined what code status the patient had chosen.

Upon patient client record review, 1 of 13 records (Patient #11) did not evidence that each patient record contains physician orders. The patient was discharged for cause. There was not evidence of a discharge order from the medical director.

Upon client record review, 1 of 13 records (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon client record review, 1 of 13 records (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management

Upon client record review, 1 of 13 records (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6: The visit frequency for the spiritual care counselor for the benefit period 12/29/22 - 3/28/23 was 2 every 2m2, 1m1. The record indicated that the spiritual counselor conducted visits on 1/9/23, 2/6/23, and 2/23/23. Corrected on site.

Upon patient record review, 1 of 13 records (Patient #6) did not have evidence that the hospice provided the following information to the SNF: • Hospice election form and any Advance Directives specific to each patient. Corrected on site.