Every finding on record at Hebron Home Health and Hospice LLC

Upon patient record review, 1 of 19 (Patient #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 2: The medication list recorded, "Oxygen 2-4 liters per minute as needed for SOB." There was no further documented evidence found of clarification as to the delivery method of oxygen, whether nasal cannula or via face mask.

Upon patient record review, 1 of 19 (Patient #10) 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 10: The LPN documented, "a small 1cm x 1cm opening at the center of the hematoma was cleansed, and the dressing was changed." at the 12/15/25 visit. The plan of care contained no problem, goal, or interventions related to this wound or any care to be provided.

Upon patient record review, 2 of 19 (Patient #6, 18) 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 6: The plan of care recorded current frequency assignment for Spiritual Care was recorded as, "2 PRN visits every 7 days" and the LPN frequency assignment as, "2 PRN visits every 7 days." There is no further documented evidence of a routine frequency of the disciplines to meet the patient needs. Patient 18: The plan of care recorded the current frequency assignment for LPN as, "2 PRN visits every 7 days." There is no further documented evidence of a routine frequency required to meet patient needs.

Upon patient record review, 1 of 19 (Patient #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 2: The plan of care effective 11/26/25 recorded, "Oxygen 2 -4 liters per minute as needed for SOB." There was no further documented evidence found of clarification as to the delivery method of oxygen, whether nasal cannula or via face mask.

Upon client record review, 1 of 19 (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: The plan of care effective 10/11/25 records Chaplain frequency as 1 x monthly and 4 PRN visits for spiritual needs. The chaplain completed visits on 11/01/25, 11/13/25, and 11/26/25. These visits were all indicated as "routine" with no documented evidence of the need or request for a PRN visit.

Upon personnel record review, 1 of 13 (Personnel # 2) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel #2: The aide education record showed documentation of completed education modules with the dates of completion but there is no documented evidence found of the hours spent to complete the required education.

Upon patient record review, 1 of 19 (Patient #2) 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 2: The patient has a history of long term use of blood thinner and/or antiplatelet therapy and documented high fall risk. The aide instructions from the time of admission through the last update on 11/06/25 did not list bleeding precautions or fall precautions related to patient safety.

Upon patient record review 1 of 19 (Patient #1) 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 aide instructions recorded the need for a shower 3 times weekly. The aide visit dated 12/10/25 did not indicate that a shower took place or of any refusal by the patient or caregiver.

Upon personnel record review, 1 of 13 (Personnel # 1) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #1: The employee file for the alternate administrator did not contain a signed job description for the role. This was obtained on-site by the agency and placed in the employee's file.

Upon patient client record review, 1 of 19 (Patient #13) 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 13: The 10/31/25 visit recorded, "wound care provided during visit and tolerated without distress" and at the 11/03/25 visit the skilled nurse documented, "wound care provided." There was no further documentation of the nursing care provided related to the wound care, it is unclear what treatments were provided.

Upon patient record review 1 of 13 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: Admitted 12/12/22 psychosocial comprehensive assessment completed on 01/04/2023.

Upon patient record review, 6 of 13 (Patient #1,#2,#4,#6,#7,#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: Mapap 325mg 2 tablets oral every 6 hours PRN. Acetaminophen- codeine 300-30mg 1 tab oral 4 hours PRN. No evidence of indicator for PRN listed on med profile for either medications. Corrected on site. Patient 2: Miralax 17grams 1 powder pack orally 1 time a day as needed for constipation. No evidence of diluent or amount of diluent entered on med profile. Corrected on site. Patient 4: Miralax 17grams 1 powder pack orally 1 time a day for constipation. No evidence of diluent or amount of diluent entered on med profile. Corrected on site. Patient 6: Acetaminophen 500mg 1 tab oral 6 hours PRN. No evidence of indicator for PRN listed on med profile. Corrected on site. Patient 7: Order for Oxygen written as "Oxygen 2-4 liters as needed for shortness of breath". Written on med profile as Oxygen 2-4 liters as needed. Dilaudid order written as "Dilaudid 4mg/ml 0.25-2ml Q1 hour as needed for pain or SOB". Written on med profile as Dilaudid 4mg/ml 0.25/2ml Q1 hour as needed. No evidence of indicator listed on med profile. Order for Tylenol written as "Tylenol 8 hours 650mg tablet ER". Written on med profile as Tylenol 650mg ER every 4 hours as needed. No evidence of route or indicator listed on med profile. Patient 10: Miralax 17grams 1 powder pack orally 1 time a day as needed for constipation. No evidence of diluent or amount of diluent entered on med profile. Order for Morphine written as "Morphine 0.25-2ml solution every hour as needed". Written on med profile as Morphine 0.025ml-2ml solution Q1 hour as needed for pain. Order for Tylenol 650mg written as 1 supp rectally every 4 hours as needed. Written on med profile as Tylenol 650mg 1 supp every 6 hours as needed for fever. No numerical indicator for fever listed on med profile. Order for Phenergan written as 1 tablet orally every 4 hours PRN for nausea and vomiting. Written on med profile as Phenergan 1 tab po every 6 hours as needed for nausea and vomiting. All corrected on site.

Upon patient record review, 6 of 13 (Patient #1,#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 medications and treatments. Patient 1: Mapap 325mg 2 tablets oral every 6 hours PRN. Acetaminophen- codeine 300-30mg 1 tab oral 4 hours PRN. No evidence of indicator for PRN listed within order for either medications. Corrected on site. Patient 2: Miralax 17grams 1 powder pack orally 1 time a day as needed for constipation. No evidence of diluent or amount of diluent entered within order. Corrected on site. Patient 4: Miralax 17grams 1 powder pack orally 1 time a day for constipation. No evidence of diluent or amount of diluent entered within order. Corrected on site. Patient 6: Acetaminophen 500mg 1 tab oral 6 hours PRN. No evidence of indicator for PRN listed within order. Corrected on site. Patient 7: Order for Tylenol written as "Tylenol 8 hours 650mg tablet ER as needed". No evidence of route or indicator listed on med profile. Corrected on site. Patient 10: Miralax 17grams 1 powder pack orally 1 time a day as needed for constipation. No evidence of diluent or amount of diluent entered within order. Morphine 0.25-2ml solution every hour as needed. No indicator listed in order. Tylenol 650mg 1 supp rectally every 4 hours. No indicator listed in order. All 3 corrected on site.

Upon patient record review 1 of 13 (Patient #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 7: Aide has missed visits on 12/26/2022 and 01/02/2023 for "Holiday scheduling" with no evidence that CG/patient refused or an order to decrease the visit frequency for this week. Corrected on site.

Upon patient client record review, 1 of 13 (Patient #11) did not evidence that each patient record contains physician orders. Patient #11: Patient revocated from services on 04/17/2022. No evidence of signed MD discharge order noted on the chart.