Every finding on record at Family Hospice, Ltd.

Upon patient record review, 5 of 19 (Patient #1,#3,#4,#5,#9) 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: Miconazole was on the facility medication profile, but not on the hospice medication profile. COS Patient #3: The patient indicated she was taking Flonase and using Systane daily; there was no evidence of either on the medication profile. COS Patient #4: The patient's sister indicated the patient was taking Magnesium Glycinate, but there was no evidence this was on the medication profile. COS Patient #5: On 08-28-25 and 09-11-25, the SN documented the patient was using medicated mouthwash that was helping with dental sores and fever blisters, however medicated mouthwash was not on the medication profile. In addition, on 09-11-25 the SN documented the patient "will use mag Citrate for constipation", however, there was no evidence that mag Citrate was on the medication profile. COS Patient #9: On 09-02-25, the NP and the RN documented the patient was "currently on antibiotics" and on 09-04-25, the MD documented the patient was taking Keflex for a UTI. However, Keflex was not on the medication profile.

Upon patient record review, 1 of 19 (Patient #6) 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 #6: At admission, the SN indicated the patient had a foley catheter and the MD documented the patient had a foley catheter on the CTI signed 08-04-25. However, there was no evidence the initial plan of care included the foley catheter or related care.

Upon patient record review, 4 of 19 (Patient #1,#3,#4,#5) 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: Miconazole was on the facility medication profile, but no evidence of order. COS Patient #3: The patient indicated she was taking Flonase and using Systane daily; there was no evidence of orders. COS Patient #4: The patient's sister indicated the patient was taking Magnesium Glycinate, but there was no evidence orders. COS Patient #5: The SN visit notes dated 08-28-25 and 09-11-25 indicated the patient was using medicated mouthwash and Mag Citrate, but there was no evidence of a physician's order. COS

Upon patient record review, 2 of 19 (Patient #11,#13) 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 #11: On the recert CTI dated 06-04-25, the MD indicated the patient had decided to no longer check his blood sugar daily and he had discontinued anti-glycemics. However, there was no evidence the care plan interventions were updated after 06-04-25 for daily glucose monitoring via FSBS. COS Patient #13: Upon admission, the MSW reached out to the patient to schedule an evaluation on 08-22-25 and 08-25-25 with no response. The plan of care dated 09-02-25 indicated the social work frequency was one time for eval, however there was no evidence of further contacts or documentation the patient declined a social work visit.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved. Patient #17: The bereavement plan of care documented the need for a sympathy card within 2 weeks of death. However, there was no evidence a sympathy card had been sent.

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: The aide was ordered 3 x week beginning 07-28-25, but the aide completed 15 missed visit notes dated 08-01-25, 08-04, 08-08, 08-11, 08-15, 08-18, 08-25, 08-29, 09-01, 09-03, 09-10, 09-12, 09-15, and 09-17-25. However, there was no evidence the aide care plan was updated by the responsible RN during this time.

Upon patient client record review, 3 of 19 (Patient #3,#5,#8) 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 #3; A supervisory visit was completed on 07-10-25, but there was no evidence of a CNA visit until 07-14-25. Patient #5: An aide supervisory visit was documented on 03-26-25, but there was no evidence of a CNA visit until 05-13-25. Patient #8: An aide supervisory was completed on 08-21-25 and 08-28-25 and the SN documented "yes" the aide had visited in the last 14 days. However, the last evidence of an aide visit was 07-31-25.

Upon patient record review 1 of 13 (Patient #9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and 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 #9: The was not evidence that the comprehensive assessment included spiritual needs.

Upon patient record review, 4 of 13 (Patient #1, #5, #9, #10) 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 listed on 06/29/2022 acetaminophen 325 mg, 2 tablets by mouth every 6 hours PRN for general discomfort and on 06/29/2022 butalbital-acetaminophen-caffeine 50mg-325mg-40mg, take one capsule every 6 hours PRN for headache however, there was no evidence of a maximum allowable dose. [corrected on site] Patient #5: The medication profile listed on 09/23/2022 oxygen prn for shortness of breath however did not indicated a liter flow. In addition, on 09/23/2022 albuterol 2.5mg/3mL PRN without an indicator for PRN use. Also, on 09/23/2022 polyethylene glycol 3350 17gm dose oral powder 1 scoop 2 times per day PRN constipation without evidence of complete directions for use. [corrected on site] Patient #9: The medication profile listed neomycin-polymyxin-hydrocortisone 3.5mg/mL 1% ear solution 5 drops each ear every 6 hours until symptoms resolve ordered 04/06/2022. The nurse confirmed symptoms resolved however, medication was still active. [corrected on site] Patient #10: The medication profile listed on 08/19/2022 Tylenol 2 tablets every 8 hours PRN pain/fever and on 08/19/2022 hydrocodone 10-325mg 2 tablets every 4 hours PRN pain with no maximum allowable dose. In addition, on 03/02/2022 Miralax give 17 gram daily without evidence of complete directions for use. [corrected on site]

Upon patient record review, 4 of 13 (Patient #1, #5, #9 #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 medications and treatments. Patient #1: There were orders on 06/29/2022 acetaminophen 325 mg, 2 tablets by mouth every 6 hours PRN for general discomfort and on 06/29/2022 butalbital-acetaminophen-caffeine 50mg-325mg-40mg, take one capsule every 6 hours PRN for headache however, there was no evidence of a maximum allowable dose. [corrected on site] Patient #5: There were orders on 09/23/2022 oxygen prn for shortness of breath however did not indicated a liter flow. In addition, on 09/23/2022 albuterol 2.5mg/3mL PRN without an indicator for PRN use. Also on 09/23/2022 polyethylene glycol 3350 17gm dose oral powder 1 scoop 2 times per day PRN constipation without evidence of complete directions for use. [corrected on site] Patient #9: There was an order for neomycin-polymyxin-hydrocortisone 3.5mg/mL 1% ear solution 5 drops each ear every 6 hours until symptoms resolve ordered 04/06/2022. The nurse confirmed symptoms resolved however, medication was still active. [corrected on site] Patient #10: There were orders on 08/19/2022 Tylenol 325mg 2 tablets every 8 hours PRN pain/fever and on 08/19/2022 hydrocodone 10-325mg 2 tablets every 4 hours PRN pain with no maximum allowable dose. In addition, on 03/02/2022 Miralax give 17 gram daily without evidence of complete directions for use. [corrected on site]

Upon patient record review, 5 of 13 (Patient #3, #4, #5, #6, #8) 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 noted on 09/20/2022 note that patient used a walker however, this was not listed on plan of care. [corrected on site] Patient #4: The social work noted in her comprehensive visit patient used a cane and the nurse visit on 09/21/2022 noted patient used a walker however, these were not listed on plan of care. [corrected on site] Patient #5: The initial nurse visit indicated the patient had a hospital bed, over bed table, oxygen, and wheelchair however, these were not listed on plan of care. [corrected on site] Patient #6: The record had several notes from nurse and social worker that indicated patient had a wheelchair however, this was not listed on plan of care. [corrected on site] Patient #8: The notes from nurse and nurse practitioner noted the patient had a hospital bed however, this was not listed on the plan of care. [corrected on site]

Upon patient record review, 1 of 13 (Patient #2) 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 #2: The note from RN on 09/02 that a request would be sent to evaluate patient for discharge. In IDG note on 09/7 indicated "CTM for appropriate hospice status due to improvement after COVID" and "patient thriving, gaining weight, and eating well. Agrees he is no longer in need of hospice services". Then on 09/09 a note that patient cannot find a physician so wants to stay on hospice" however, plan of care was not updated to assist patient with resources.

Upon client record review, 6 of 13 (Patient #1, #2, #3, #4, #6, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The orders for nursing visit frequency on 06/29/2022 were 2week3, 1week11, and 4 PRN however, the week of 07/10/2022 there was only evidence of one visit on 07/12/2022. In addition the nursing order on 09/18/2022 were 4week1, 2week1 however, the week of 09/18/2022 there was only evidence of three visits on 09/22,9/23,9/24/2022. The spiritual care order on 09/01/2022 was 5month1 however, there was only evidence of routine visit on 09/01 and 09/26/2022. Patient #2: The orders for nursing services on 06/02/2022 were 1week14, 4 PRN however, the week of 7/10/2022 there was no evidence of a visit. In addition, the social worker visit frequency on 06/02/2022 was 1M, 2 PRN however, there was no evidence of a visit in July. Patient #3: The nursing visit frequency was ordered on 07/18/2022 as 1week8, 4 PRN and 09/14/2022 as 1 every 2week 2, 1week7 however, the week of 9/11/2022 there was no evidence of a routine nursing visit. [corrected on site] Patient #4: The nursing visit frequency 09/21/2022 was 1 every 2week 2, 1week 7, 4 PRN however, the week of 09/21 there was no evidence of a routine visit. [corrected on site] Patient #6: The nursing visit frequency 06/16/2022 was 2week2, 1week12, 4 PRN and 09/14/2022 1 every2week2, 1week12, 4 PRN however, the week of 09/11/2022 there was no evidence of a routine nursing visit. [corrected on site] Patient #11: The nursing visit frequency 2/13 was 2week1, 1week8, 5 PRN however, the week of 02/13 there were 3 nurse visits performed on 2/15, 2/17, 2/19/2022 .

Upon patient record review 4 of 11 applicable (Patient #1, #6, #8, #11) 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: The order for aide visit frequency 6/29/2022 was 1week1, 2week12, 1week1 however, the week of 08/07/2022 there was only evidence of one visit on 08/10/2022. Patient #6: The order for aide visit frequency 06/16/2022 was 1week1, 3week12, 1 week1 however, the week of 07/17/2022 there was only evidence of 2 visits on 07/20 and 07/22. Patient #8: The aide visit frequency 07/13/2022 was 2week1, 3week8 and on 09/11/2022 3week8, 2week1 however, the week of 07/18 only two visits complete and the week of 09/18 two visits completed. Patient #11: The aide visit frequency was 2week8, 1week1 on 02/13 however, there was only one visit the week of 2/13.

Upon patient record review, 1 of 13 (Patient #3) 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 #3: The CTI included the name different than the patient in physician narrative.

Upon client record review, 1 of 1 applicable (Patient #13) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #13: The administrator confirmed this patient transferred to another hospice however, the record did not contain evidence that transfer summary was forwarded.

Upon client record review, 1 of 3 applicable (Patient #5) 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 #5: The patient resided in a facility however, there was no facility coordination on plan of care. [corrected on site]