Every finding on record at Family Hospice, Ltd.

Upon patient record review, 4 of 19 (Patient #1,4,7,11) 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: RN documentation indicated that the patient uses oxygen at 4LPM NC as needed for shortness of breath. No evidence that oxygen was added to the active medication profile. Patient 4: Duplicate drug therapy. The active medication profile had 2 orders for corn starch topical powder with the same instructions. Patient 7: Medication profile has an order for oxygen. No evidence that a delivery route was added to the active medication profile. Patient 11: Medication profile has an order for MiraLax 17g daily by mouth as needed. No evidence that a diluent was added to the active medication profile.

Upon patient record review, 2 of 19 (Patient #3,17) 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 3: Bereavement risk assessment completed 12 days after the day of admission. Patient admitted on 11/02/2025, risk assessment completed on 11/14/2025. Patient 17: No evidence that a bereavement risk assessment was completed at the time of admission. The only documented bereavement risk assessment occurred 3 days after the patient expired on 02/21/2025.

Upon patient record review, 2 of 19 (Patient #12,13) 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 12: No evidence that an RN comprehensive assessment was completed every 15 days between 12/17/2025 and 1/07/2026. 21 days between assessments. Patient 13: No evidence that an RN comprehensive assessment was completed every 15 days between 12/12/2025 and 1/06/2026. 25 days between assessments.

Upon patient record review, 7 of 19 (Patient #1,2,6,7,9,11,13) 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 1: RN documentation indicated that the patient was a high risk for falls, has a history of seizures and takes 3 different seizures medications daily, and has contractures to his right arm. No evidence that problems, goals, interventions related to fall safety, oxygen safety, seizures, or altered mobility was added to the plan of care. Patient 2: Patient identified as a risk for aspiration upon admit and ongoing via RN assessments. The patient is also currently using oxygen as needed. No evidence that problems, goals, and interventions related to safety for aspirations, and safety related to oxygen usages added to the plan of care. Patient 6: Patient identified as risk for falls on RN documentation. No evidence that problems, goals, and interventions related to fall safety was added to the plan of care. Patient 7: Patient identified as a risk for falls and risk for aspiration in ongoing RN assessments. No evidence that problems, goals, and interventions related to safety of falls and risk for aspirations added to the plan of care. Patient 9: Pre-bereavement risk assessment was completed by the nurse at the time of admit (08/15/2025) and was scored as moderate. No evidence that a follow-up was completed or that support was offered to the caregiver at the time that the need was identified. No evidence that the admitting nurse communicated the moderate pre-bereavement risk with the IDG team. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 11: The patient currently takes Eliquis daily for anticoagulation therapy. No problems, goals, and interventions related to risk for bleeding added to the plan of care. Patient 13: Two bereavement contacts identified at the time of admit, the patients spouse and daughter. Pre-bereavement risk assessment was completed with the daughter by the nurse at the time of admit (11/22/2025) and scored as high. The chaplain completed another assessment with the daughter on 11/28 that also scored high. The MSW completed an assessment with the spouse on 11/26/2025 that scored as high. No evidence that a follow-up was completed or that support was offered to the daughter at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the needs of both the spouse and the daughter.

Upon patient record review, 2 of 19 (Patient #1,11) 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: RN documentation indicated that patient uses oxygen at 4LPM NC as needed for shortness of breath. No evidence that an order for oxygen was obtained by the physician. Patient 11: An order for MiraLax 17g daily by mouth as needed was entered on 1/17/2026. No evidence that a diluent was added to the order at the time that the chart was surveyed.

Upon patient record review, 5 of 19 (Patient #2,4,6,7,10) 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 2: RN documentation indicated that the patient uses a Hoyer lift daily due to altered mobility and has active orders for oxygen. No evidence that the Hoyer lift or the oxygen/oxygen supplies was placed on the active supply list. Patient 4: The current plan of care has orders nebulizer treatment every 4 hours as needed. No evidence that nebulizer supplies listed on the active supply list. Patient 6: Plan of care has no DME or supplies list on the plan of care. The medical indicated that the has active wounds that require wound supplies, uses a wheelchair daily for mobility, uses oxygen at 3LNC as needed for shortness of breath, and uses incontinent supplies daily for bowel and bladder incontinence. Patient 7: Nurse documentation indicates that patient uses a wheelchair due to altered mobility and weakness. No evidence that the wheelchair was listed on the current supply list. Patient 10: The current supply list has foley catheter supplies. No evidence that the patient has had a foley catheter since being admitted.

Upon patient record review, 3 of 19 (Patient #4,6,10) 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 4: The current plan of care has interventions listed for the SN to instruct the patient/caregiver on ordered treatment for UTI. No evidence that the patient has been treated for a UTI since July 2025. Patient 6: The chaplain visits ended on 12/29/2025. Spiritual problems, goals, and interventions remains on the active plan of care. Patient 10: The current plan of care has problems, goals, and interventions related to physical therapy. The medical record indicates that the patients therapy treatment ended on 02/18/2025.

Upon patient record review 2 of 19 (Patient #9,13) 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 9: Pre-bereavement risk assessment was completed by the nurse at the time of admit (08/15/2025) and was scored as moderate. No evidence that a follow-up was completed or that support was offered to the caregiver at the time that the need was identified. No evidence that the admitting nurse communicated the moderate pre-bereavement risk with the IDG team. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 13: Two bereavement contacts identified at the time of admit, the patients spouse and daughter. Pre-bereavement risk assessment was completed with the daughter by the nurse at the time of admit (11/22/2025) and scored as high. The chaplain completed another assessment with the daughter on 11/28 that also scored high. The MSW completed an assessment with the spouse on 11/26/2025 that scored as high. No evidence that the other members of the IDG team was notified of either bereavement risk assessments. No evidence that a follow-up was completed or that support was offered to the daughter at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the needs of both the spouse and the daughter.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 8: The medical record indicated that the patient fell on 12/25/2025. No evidence that the fall was investigated at the time of survey.

Upon observation during home visit 1 of 4, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #4: During the home visit, the hospice nurse placed her dirty equipment (blood pressure cuff, pulse ox, stethoscope, thermometer) into her bag without cleaning them first. Also during the visit, the nurse placed her shoulder bag in the chair without a barrier of any sort.

Upon patient record review, 1 of 19 (Patient #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 6: No evidence that the aide plan of care included instructions for fall precautions, bleeding precautions, oxygen safety, and wound precautions.

Upon patient record review 2 of 19 (Patient #4,7) 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: Plan of care has aide frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 02/1/2026. No evidence that these visits were missed at the request of the patient/CG or that an order was received to decrease visits for the week. Patient 7: Plan of care has aide frequency ordered as 2 times a week starting 12/28/2025. The medical record indicated that the patient received 3 visits for the week of 12/28/2025. No evidence that an order was received to increase the visits for that week. The medical record indicated that the patient received one visit for the week of 01/04/2026. No evidence that the 2nd visit was missed at the request of the patient/caregiver or that an order was received to decrease the visit frequency for the week.

Upon patient record review 1 of 19 (Patient #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 11: No evidence that a registered nurse made an aide supervisory visit every 14 days between 11/21/25-12/29/25 (38 days) and again between 01/09/2026-01/26/2026 (17 days).

Upon patient client record review, 1 of 19 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 5: Informed consent/election of benefits signed by the patients POA/legal representative. No evidence that the legal representative's printed name, number, and address was completed at the time of admission. Those areas where left completely blank.

Upon client record review, 2 of 19 (Patient #15,16) did not have evidence that the discharge summary includes all required information. Patient 15: No evidence that a discharge summary was completed at the time the chart was surveyed. Patient 16: No evidence that a discharge summary was completed at the time the chart was surveyed.

Upon patient record review, 4 of 13 records (Patient #4,#7,#9,#11) 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 #4: The medication profile contained Acetaminophen 325mg tabs, 2 q4h prn temp and Acetaminophen 650mg rectal supp 1 q4h prn temp. There was not evidence of parameters for the temp. Corrected on site. Patient #7: The medication profile contained Acetaminophen 500mg tabs, 1 q4h prn pain or fever. There was not evidence of parameters for the temp. Corrected on site. Patient #9: The medication profile contained Acetaminophen 650mg rectal supp, 1 q4h prn temp. There was not evidence of parameters for the temp. Corrected on site. Patient #11: The medication profile contained Acetaminophen extra strength 500mg tabs, 1 q8h prn pain or fever. There was not evidence of parameters for the temp. In addition, Dermatological, apply small amount to affected area q6h as needed. There was not evidence of a location.

Upon patient record review, 4 of 13 records (Patient #3,#4,#7,#8) 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 #3: The patient was admitted on 5/18/22. The record indicated that the bereavement assessment was not completed until 10/25/22. Patient #4: The patient was admitted on 12/9/22. The record indicated that the bereavement assessment was not completed until 1/6/23. Patient #7: The patient was admitted on 9/13/22. The record indicated that the bereavement assessment was not completed until 1/7/23. Patient #8: The patient was admitted on 5/27/22. The record indicated that the bereavement assessment was not completed until 6/10/22.

Upon patient record review, 3 of 13 records (Patient #9,#11,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient 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 #9: The patient was admitted with a diagnosis of Alzheimer's Disease. There was not evidence that the plan of care reflected patient/family goals and interventions based on Alzheimer's Disease and neurological problems identified in the initial, comprehensive, and updated comprehensive assessments. Corrected on site. Patient #11: The patient was admitted with a diagnosis of Parkinson's Disease. There was not evidence that the plan of care reflected patient/family goals and interventions based on the neurological problems identified in the initial, comprehensive, and updated comprehensive assessments. The record indicated that the patient had difficulty walking, had recent falls, was forgetful and had an unsteady gait. She was also on Sinemet. Patient #13: The patient was admitted with a diagnosis of Alzheimer's Disease. There was not evidence that the plan of care reflected patient/family goals and interventions based on the Alzheimer's Disease and neurological problems identified in the initial, comprehensive, and updated comprehensive assessments.

Upon patient record review, 4 of 13 records (Patient #4,#7,#9,#11) 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: The record contained an order for Acetaminophen 325mg tabs, 2 q4h prn temp and Acetaminophen 650mg rectal supp 1 q4h prn temp. There was not evidence of parameters for the temp. Corrected on site. Patient #7: The record contained an order for Acetaminophen 500mg tabs, 1 q4h prn pain or fever. There was not evidence of parameters for the temp. Corrected on site. Patient #9: The record contained an order for Acetaminophen 650mg rectal supp, 1 q4h prn temp. There was not evidence of parameters for the temp. Corrected on site. Patient #11: The record contained an order for Acetaminophen extra strength 500mg tabs, 1 q8h prn pain or fever. There was not evidence of parameters for the temp. In addition, Dermatological, apply small amount to affected area q6h as needed. There was not evidence of a location.

Upon client record review, 1 of 13 records (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. The visit frequency for the skilled nurse was 2x/week. For the week of 2/5/23-2/11/23, the record indicted only 1 routine visit on 2/11/23.

Upon patient record review, 2 of 13 records (Patient #4,#11) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions and precautions/alerts for a hospice aide that are prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #4: The record indicated that the patient was having frequent falls. A fall occurred on 12/31/23 which required a prn visit by the nurse. There was not evidence that fall precautions were added to the aide plan of care. Corrected on site. Patient #11: The record indicated that the patient had a history of frequent falls. There was not evidence that fall precautions were on the aide plan of care.

Upon patient record review 5 of 13 records (Patient #1,#4,#5,#6,#7) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The visit frequency for the aide was 3x/week (effective 1/22/23). For the week of 1/29/23-2/4/23, the record indicated only 2 missed visits documented on 2/1/23 and 2/3/23. In addition, the aide plan of care indicated for a shower. Upon observed home visit, the aide was observed providing a bed bath without first notifying the nurse to obtain a revision to the care plan. Patient #4: The visit frequency for the aide was 2x/week. For the week of 1/1/23-1/7/23, the record indicated only 1 visit documented on 1/5/23. Patient #5: The aide visit frequency was 2x/week. For the week of 1/29/23-2/4/23, the record indicated only 1 visit on 2/2/23. Patient #6: There was a missed visit document dated 12/17/23 which indicated that the reason for the missed visit was that the aide 'was out.' In addition, the visit frequency was 3x/week. For the week of 1/29/23-2/4/23, the record indicated only 1 visit on 2/1/23. Patient #7: The aide plan of care indicated to provide nail care weekly. The aide documentation indicated that nail care was performed at each visit.

Upon patient client record review, 3 of 13 records (Patient #4,#7,#13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #4,#7,#13: The record indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished.

Upon patient client record review, 1 of 13 records (Patient #6) did not have evidence that each patient record contains Advance Directives. Patient #6: The record indicated that the patient had an Advance Directive. There was not evidence that these documents were on the record.

Upon client record review, 1 of 13 records (Patient #9) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #9: The record indicated wound care orders dated 2/22/23, " Cleanse skin tear right arm with normal saline. Pat dry, apply silver collagen, apply petrolatum gauze. Cover with NAD pad. Wrap with Kerlix and secure with tape 2x/day and prn loose or soilage." There was not evidence of who was to perform the dressing change and wound care. Corrected on site.

Upon patient record review, 2 of 13 records (Patient #9,#10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient #9: The most recent plan of care on the record at the SNF was dated 12/10/22. Patient #10: The most recent plan of care on the record at the SNF was dated 1/11/23.