Every finding on record at First Call Hospice LLC

Upon patient record review, 5 of 5 (Patients #1,#2,#3,#4,#5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law.

Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) 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 medical record contained an order 9/17/25 for oxygen rate, frequency, and delivery method. There was no evidence of oxygen listed on the medication profile. The medication profile contained latanoprost eye drops with no instructions for which eye or eyes require administration. Patient 2: The medical record contained nursing documentation 10/4/25 identifying patient use of Advil. There was no evidence of Advil listed on the medication profile. Patient 3: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 4: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The medication profile also contained Miralax oral powder with no instructions to mix with a diluent.

Upon patient record review, 1 of 5 (Patient #1) 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 1: The medical record contained an order for wound care 9/30/25. There was no evidence of wound assessments or measurements after 9/30/25.

Upon patient record review, 1 of 5 (Patient #1) 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: The medical record contained nursing documentation identifying patient issues with dysphagia and use of Eliquis listed in medications since admission. There was no evidence of problems, goals, and interventions related to risks for aspiration and bleeding included in the plan of care.

Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) 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 medical record contained an order for latanoprost eye drops with no instructions for which eye or eyes requiring administration. Patient 2: The medical record contained nursing documentation 10/4/25 identifying patient use of Advil. There was no evidence of an order for Advil dose and frequency. Patient 3: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Patient 4: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. The record also contained an order for Miralax oral powder with no instructions to mix with a diluent.

Upon patient record review, 4 of 5 (Patients, #1,#2,#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 equipment and supply needs. Patient 1: The medical record contained an order 9/17/25 for oxygen rate, frequency, and delivery method and nursing documentation upon admission identifying patient use of a Hoyer lift for transfers. There was no evidence of orders for the DME included in the plan of care. Patient 2: The medical record contained nursing documentation 10/4/25 identifying a commode was ordered to be delivered by the supplier. There was no evidence of an order for the DME included in the plan of care. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for the oxygen DME included in the plan of care. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of hospital bed, overbed table, commode, and wheelchair. There was no evidence of orders for the DME included in the plan of care.

Upon client record review, 1 of 5 (Patient #5) 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 medical record contained nursing documentation 10/3/25 identifying nurse increased oxygen flow rate from one to three liters per minute. There was no evidence of an order for oxygen.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. The administrator did not have access to EMR and additional knowledge of the hospice program to start the survey resulting in an hour and a half delay until the director arrived.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 5 (Patient #1, 2) 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 taking Sennosides 8.6mg po prn constipation. (bottle found in home). This medication is not listed on the medication profile. Corrected on Site Patient #2: Patient using Albuterol inhaler prn shortness of breath. (found in home) This medication is not listed on the medication profile. Corrected on Site

Upon patient record review, 2 of 5 (Patient #1, 2) 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 taking Sennosides 8.6mg po prn constipation. This medication is not listed on the Plan of Care orders. Corrected on site. Patient #2: Patient using Albuterol inhaler prn shortness of breath. This medication is not listed on the Plan of Care orders. Corrected on site.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: PRN visit completed by RN on 09/07/24 at 14:00 for "leaking catheter". RN documents," irrigated with 50cc normal saline." Supplemental order written and states "flush with 30cc normal saline".

Upon patient record review 1 of 5 (Patient #5) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #5: Aide care plan indicates "assist to toilet, assist to bedside commode, stand by assist with ambulation" are to be performed every visit. Aide note dated 07-19-24 hospice aide marked, “NO-patient not able", for assist to toilet, assist to bedside commode and ambulation". No documentation that RN was notified.

Upon patient client record review, 1 of 5 (Patient #1) 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 #1: Acknowledgement of receipt of Patient Rights and Responsibilities was signed by patient with the date of 08/08/24 on the signature line, which was incorrect. Hospice representative signed and dated 08/18/24. All other consents were signed 08/18/24.