Every finding on record at Firsthand Hospice Inc.

Upon patient record review, 2 of 14 (Patient #3, 5) 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 #3: Upon observation during home visit, noted hospice medication profile includes 6/19/25 Nystatin 100,000 units/ml suspension 5 ml 3 times/day for oral thrush. Caregiver reports the original order was x7 days and the medication was discontinued at that time. Hospice RN agrees should have been updated/discontinued. Patient #5: Upon observation, during home visit, hospice medication profile includes 4/23/25 Metoprolol Tartrate 25 mg tablet (1/2 tab) twice/day. Hold if SBP >120 or HR <60. (should read <120). The prescription bottle says dose (1) 25 mg tab. CG reportedly administering 1 tab when blood pressure not less than 120.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Patient has Oxygen prescribed at 2LPM via NC. There are no related problems, goals interventions.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 6, 7, 8) did not have evidence the plan of care must 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 • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: Order effective 8/11/25 SC visit frequency of every certification period and as needed. As needed is not quantified. Patient #2: Orders effective 8/13 and 10/12/25 for SC frequency of visits every cert and as needed ...As needed is not quantified. Patient #3: Order 8/7/25 SC 1 every cert and as needed. 8/21/25 MSW monthly and prn. As needed and prn are not quantified. Patient #6 Orders effective 4/11/25 and 7/10/25: MSW frequency orders for visit monthly and as needed. As needed is not quantified. Patient #7: Order effective 12/1/24 SC every recert and as needed. As needed is not quantified. Patient #8: Orders effective 9/9/24 and 12/8/24: MSW visits every recert and as needed to provide psychosocial. As needed is not quantified.

Upon patient record review, 2 of 14 (Patient #2, 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 #2: 12/15/24: Treatment for coccyx stage 2 skin breakdown ...Clean skin with mild soap and water. Pat dry. Apply Calmoseptine daily and as needed. As needed is not qualified. Patient #4: 7/24/25 Order for redness to coccyx. Clean area with mild soap and water. Pat dry. Apply Calmoseptine to coccyx daily and as needed. As needed is not qualified.

Upon client record review, 5 of 14 (Patient #1, 2, 4, 6, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 10/21/23. 7/31/25 Frequency order effective for MSW monthly and 1 prn. No Aug, Sept visits noted. MSW documented attempts to make contact 8/4/25. However, there was no mention/coordination with IDG regarding difficulty making contact to facilitate and/or to update IDG/POC. Patient #2: 8/10/25 MSW frequency order: Assessment within 5 days of recert then 1x as needed for psychosocial support for 8th benefit 8/13-10/22/25. No recert visit made. The only visit documented was 10/2/24 initial assessment. Patient #4: SC initial orders 7/9/25 for visit within 5 days of admission, certification, and 1 as needed. (Cert period 7/9/25-10/6/25) SC visits documented monthly instead (7/13, 8/20, 9/25/25). Patient #6: SOC 4/11/25. Initial SC frequency of 1/month and 2 prn. No June visit documented for 4/11-7/9/25 benefit period. No documented patient refusal. 8/20/25 Volunteer frequency one per month and 3 as needed per family request. Volunteer visits documented 8/22, 8/29, 10/3/25. There was no September visit documented. Patient #7: Order effective 12/1/24 start SC every recert and as needed. SC visits documented 12/6/24 and 1/25/25 (cert period 12/1-1/29/25).

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Patient has Oxygen ordered 7/9/25 2LPM/NC. Oxygen is blank on aide assignment sheets dated 7/9/25 and 10/7/25 for oxygen treatment, flow rate, frequency or precautions.

Upon patient client record review, 4 of 14 (Patient #5, 8, 9, 11) 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 #5: 9/17/25 Initial bereavement assessment is not authenticated with clinician's signature. Patient #8: 12/08/24 MSW visit note time in and out entered but note is blank and not authenticated with clinician's signature. Patient #9: 11/20/24 MSW visit note not authenticated with clinician signature. 9/10/25 DC Summary not authenticated with signature. Patient #11: 9/28/25 Note titled Report of Death and Disposal of Controlled Drugs is not authenticated with clinician's signature.

Upon personnel record review, 1 of 11 (Personnel #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #8: There is no documented criminal background check.

Upon patient record review, 5 of 5 records (Patients #1,#2,#3,#4,#5) 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 #1, 2, 3, 4, 5: There is no evidence that an initial bereavement assessment was completed.

Upon patient record review, 1 of 3 applicable (Patient #1) 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 provides care 1 time a week; however there is no evidence that the aide care plan/assignment has been completed by the RN. Aide assignment in the medical record is blank.

Upon personnel record review, 1 of 5 applicable (Personnel #9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Patient #9: There was no evidence of a background check being obtained for the Alternate Medical Director