Every finding on record at Grace of the Pines Hospice LLC

Upon patient record review, 4 of 19 (Patient #3, #8, #10, #13) did not contain 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: The medication list contains Atropine eye drops ordered for "eyes" but the note section states to be given for "noisy breathing". Patient #8: 08/26/25 Oxycodone 5mg tab 1-2 tabs every 4 hours as needed. 09/19/25 Oxycodone 5mg tab 2 tabs every 4 hours as needed. 08/26/25 order should have had an end date on 09/19/25 as this was a change in medication per DCS. COS-DCS did put end date in order on site. Patient #10: Neither caboxymethylcellulose sodium eye drops or Retaine eye drops indicated which eye(s) to be applied. Patient #13: Citric acid/gluconolactone/magnesium carbonate (Renacidin) irrigation solution did not indicate what was to be "irrigated". Dextran/hypromellose (Lubricating Tears) did not indicate which eye(s) to be applied. This medication was listed two times on MAR with dates of 08/21/25 and 10/23/25. Narcotic orders all listed and unclear if concurrent or when should be administered or if some should have been discontinued: 08/21/25 Morphine IR 15mg tab 1 tab every 8hours/PRN, Morphine concentrate 20mg/mL 0.25-1mL PO/SL q1hr/PRN. 08/25/25 Morphine 100mg/5mL (20mg/mL) 0.5mL q2hrs. 10/20/25 Oxycodone 5mg 1tab q4hrs/PRN, Fentanyl 12mcg q72hrs. Oxygen - on MAR it is listed as "PRN" but per the admission note dated 08/21/25 nurse indicated that patient uses oxygen "continuous".

Upon patient record review, 4 of 19 (Patient #3, #8, #10, #13) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #3: The POC upon admission indicated Atropine eye drops for "eyes" but the note section states to be given for "noisy breathing". Patient #8: POC upon admission 08/26/25 indicated Oxycodone 5mg tab 1-2 tabs every 4 hours as needed. 09/19/25 Oxycodone 5mg tab 2 tabs every 4 hours as needed. 08/26/25 order should have had an end date on 09/19/25 as this was a change in medication per DCS. DCS did put end date in order on site. Patient #10: POC upon admission (10/24/25) did not indicate which eye(s) for either caboxymethylcellulose sodium eye drops or Retaine eye drops were to be applied to. Patient #13: POC upon admission (08/26/25) did not indicate where Citric acid/gluconolactone/magnesium carbonate (Renacidin) irrigation solution was to be used. Dextran/hypromellose (Lubricating Tears) did not indicate which eye(s) to be applied to. This medication was duplicated on POC. Narcotic orders all listed and unclear if concurrent or when should be administered or if some should have been discontinued: 08/21/25 Morphine IR 15mg tab, 1 tab oral every 8hours/PRN, Morphine concentrate 20mg/mL 0.25-1mg PO/SL q1hr/PRN. 08/25/25 Morphine 100mg/5mL (20mg/mL) 0.5mL oral q2hrs. 10/20/25 Oxycodone 5mg 1tab oral q4hrs/PRN, Fentanyl 12mcg topical q72hrs. Oxygen - on MAR it is listed as "PRN" but per the admission note dated 08/21/25 nurse indicated that patient uses oxygen "continuous".

Upon personnel record review, 2 of 12 (Personnel #6, #7) did not contain evidence that the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon patient client record review, 1 of 5 (Patient #2) 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 2: The CTI for benefit period starting 10/20/24 contained an incorrect attestation by the nurse practitioner claiming completion of the face to face instead of the medical director. The actual documentation of a face to face visit 10/9/24 was completed by the medical director.

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.

Upon patient record review, 8 of 13 (Patient #1,#2,#3,#6,#8,#9,#10,#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: On 9/5/22, the patient was admitted with Diclofenac Cream 2g to affected area, topically, for pain. There is not evidence of a specific location to apply the cream. Corrected on Site. Patient 2: The medication profile indicates the following medications were ordered: Tylenol Suppository 650mg Q6 hours per rectally for pain. Tylenol suspension 325mg/10.15ml. Give 20.3ml PO, twice daily. 3) Tylenol suspension 325mg/10.15ml. Q6 hours PRN for pain/fever. There is not evidence of a maximal allowable dose for a 24 hour period of time. There is not evidence of parameters for fever. Corrected on site. Patient 3: The medication profile indicates the patient was on Acetaminophen 325mg, two tablets twice a day and 1-2 tabs PO Q4 hours PRN for pain/fever. There is no evidence of parameters for fever. The single order contained a straight order and a PRN order in one order. The medication profile indicated Docusate Sodium 100mg, 1 tab PO, twice daily, PRN. There was no evidence of an indication for use. The medication record indicated Polyethylene Glycol 3350 1/2-1 cap Give 1/2 -1 capful daily PRN. There is no evidence of a diluent. Also, the medication profile indicates Psyllium powder for reconstitution 3.4g/11g Give as directed daily PRN. There is no evidence of a diluent. Corrected on site. Patient 6: The medication profile indicates that following medications were ordered: Acetaminophen tablet 325mg, 2 tabs PO Q2 hours PRN for pain 1-4/10 or fever greater than 100. Acetaminophen 325mg give 2 tabs Q6 hours. There is no maximum allowable dose. Corrected on site. Patient 8: The medication record indicated Miralax 17gm PO Q day, PRN for constipation. There is not evidence of a diluent. The order for Miralax was discontinued on 8/26/22 and continues to be on the active medication record. Corrected on site. Patient 9: The medication profile indicates Bacitracin was ordered to affected area topically on 7/29/22. There is not evidence of a location to apply the bacitracin. Corrected on Site. Miralax 17gm PO Q8 hours PRN for constipation was on the medication profile. There is not evidence of a diluent. Corrected on site. Patient 10: The medication record indicated Lactulose liquid 10g/15ml Give 15ml PO Q8 hours PRN orally/rectally. There is not evidence of an indication of usage. Corrected on site. Patient 13: The medication profile indicated Clotrimazole cream 1% apply topically as needed for irritated skin. There is not evidence of a site to apply the cream.

Upon patient record review, 2 of 13 (Patient #1,#6) 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: The Bereavement Assessment was completed by the MSW on 10/3/22. The patient was admitted on 9/5/22. Patient 6: There was not evidence of an initial Bereavement assessment.

Upon patient record review, 8 of 13 (Patient #1,#2,#3,#6,#8,#9,#10,#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: On 9/5/22, the patient was admitted with Diclofenac Cream 2g to affected area, topically, for pain. There was not evidence of a specific location to apply the cream. Corrected on site. Patient 2: The following medications were ordered: Tylenol Suppository 650mg Q6 hours per rectally for pain. Tylenol suspension 325mg/10.15ml. Give 20.3ml po, twice daily. Tylenol suspension 325mg/10.15ml Q6 hours PRN for pain/fever. There is not evidence of a maximal allowable dose for a 24 hour period of time. There is not evidence of parameters for fever. Corrected on site. Patient 3: Order for Acetaminophen 325mg, two tablets twice a day and 1-2 tabs PO Q4 hours PRN for pain/fever. There is no evidence of parameters for fever. The single order contained a straight order and a PRN order in one order. Order for Docusate Sodium 100mg, 1 tab PO, twice daily, PRN. There was no evidence of an indication for use. Order for Polyethylene Glycol 3350 1/2-1 cap Give 1/2 -1 capful daily PRN. There is no evidence of a diluent. Order for Psyllium powder for reconstitution 3.4g/11g give as directed daily PRN. There is no evidence of a diluent. Corrected on site. Patient 6: Orders for: Acetaminophen 325mg, 2 tabs PO Q2 hours PRN for pain 1-4/10 or fever greater than 100. Acetaminophen 325mg give 2 tabs Q6 hours. There is no maximum allowable dose. Corrected on site. Patient 8: Orders for Miralax 17gm PO Q day, PRN for constipation. There is not evidence of a diluent. Patient 9: Bacitracin was ordered to affected area topically on 7/29/22. There is not evidence of a location to apply the bacitracin. Miralax 17gm PO Q8 hours PRN for constipation was ordered. There is not evidence of a diluent. Patient 10: Order for Lactulose liquid 10g/15ml Give 15ml PO Q8 hours PRN orally/rectally. There is not evidence of what it is for. Corrected on site. Patient 13: Order for Clotrimazole cream 1% apply topically as needed for irritated skin. There is not evidence of a site to apply the cream.

Upon client record review, 2 of 8 applicable (Patient #1,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On 9/19/22 order for the Spiritual Care 1 Week 11. No evidence of visits made the weeks of 10/2/22, 10/9/22 and 10/23/22. Patient 5: The Spiritual Counselor visit frequency is 1 week 13 from start of care. There is not evidence of a spiritual Counselor visit the week of 10/9/22. Corrected on site.

Upon patient client record review, 1 of 13 (Patient #1) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1: Patient/family requested to receive notification of non-covered items. There was not evidence in the medical record that the patient/family received notification of non-covered items.

Upon client record review, 1 of 5 applicable (Patient #4) 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 4: The Social Worker and Spiritual Counselor visit frequency order on admission was 1 time a month. There is no evidence of a social worker or spiritual counselor visit in the month of October.