Every finding on record at Heritage Home Health LLC

Upon patient record review, 1 of 19 (Patient # 9) did not have evidence in the patient record that the comprehensive assessment takes into consideration complications and risk factors that affect care planning. Patient 9: The POC on 02/11/26 contains an order for Eliquis with no evidence of risk for bleeding on POC.

Upon patient record review, 3 of 19 (Patient #5, 9 and 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: Patient 5: Upon home visit medication review, spouse reports "He also takes Lumigan eye drops in both eyes." Agency medication profile does not contain eye drops observed in the home. Patient 9: The medication profile on 11/12/25 contains an order for Lidocaine patch with no evidence of location of application and when to remove. Patient 13: The medication profile on 01/13/26 contains orders for MiraLAX with no evidence of a diluent and Lidocaine patch with no specification of where to apply.

Upon patient record review, 4 of 19 (Patient # 5, 6, 9 and 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 5: The POC on 02/16/26 contains an order for wound care without specifications of who will be providing wound care and an order to place foley on 2/09/26 and change foley 2/20/26 without specifications of size/balloon/frequency or care of catheter. Upon home visit spouse reports "He also takes Lumigan eye drops in both eyes." There is no evidence of Lumigan eye drops on POC. Patient 6: There is evidence the POC 01/20/26 contains an order for "Foley catheter per pt comfort." There is no evidence of specific catheter size, balloon and frequency or catheter care. Patient 9: The POC on 11/12/25 contains an order for Lidocaine patch with no evidence of location of application and when to remove. Patient 13: The POC on 01/13/26 contains orders for MiraLAX with no evidence of a diluent and Lidocaine patch with no evidence of location of application and when to remove.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: The SN documents on 1/15/26 "foley placed with a size 14." There is no evidence of an order on POC for foley care provided.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The annual cost savings report for 2025 has evidence of volunteer cost savings of 1.73%.

Upon personnel record review, 1 of 17 (Personnel # 1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel 1: There is no evidence that administrator is a hospice employee. There is evidence of a contract for the administrator in personnel file. Administrator was hired as an employee in 2010 and changed to contractual staff in 2022.

Upon patient client record review, 1 of (Patient #5) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 5: The SN documents 2/20/26 "changed foley catheter" with no documentation of details how patient tolerated procedure.

Upon patient client record review, 1 of 19 (Patient #5) 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: The SN documents 2/20/26 "changed foley catheter" with no documentation of details such as catheter, balloon size, etc.

Upon client record review, 1 of 19 (Patient # 3) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 3: The POC on 02/24/26 contains wound care orders with no evidence of who will be providing wound care.

Upon patient record review 1 of 19 (Patient #13) 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 #13 - SOC 05/12/2022 - SC made first visit on 06/01/2022. All disciplines, per agency policy, did not complete their section of the comprehensive assessment within 5 days. SN completed spiritual assessment on admission.

Upon patient record review, 4 of 19 (Patient #7, 9, 10, 11) 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 #7 - Medication profile contained Senna 1 x day PRN, Loperamide 1 tab 4 times a day as needed, Ondansetron 1 tab every 6 hours as needed, Hydrocodone 1 tab every 4 hours PRN - PRN or "as needed" did not have modifier for reason. Patient #9 - Medication profile contained Melatonin 1 x day as needed, Loperamide 1 tab 4 times a day as needed, Ondansetron 1 tab every 4 hours as needed, Hydrocodone 1 tab every 6 hours PRN, Acetaminophen 650mg every 6 hours PRN, Guaifenesin ER 1 every 12 hours PRN - PRN or "as needed" did not have modifier for reason. Patient #10 - Medication profile contained Bisacodyl 1 x day PRN, Acetaminophen 325mg 2 tabs every 6 hours PRN - PRN did not have modifier for reason. Patient #11 - Medication profile contained Lorazepam 0.5 mg every 2 hours PRN, Morphine .25mg every 2 hours as needed- PRN or "as needed" did not have modifier for reason.

Upon patient record review, 3 of 19 (Patient #2, 6, 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 #2 - POC dated 01/16/2023 contained SC 1 PRN/month. Patient #6 - POC dated 02/09/2023 contained Vol 1 PRN visit weekly. Patient #8 - POC dated 03/29/203 contained Massage Therapy 1 PRN/month. All corrected on site.

Upon patient record review, 4 of 19 (Patient #7, 9, 10, 11) 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 #7 - POC dated 04/08/2023 contained Senna 1 x day PRN, Loperamide 1 tab 4 times a day as needed, Ondansetron 1 tab every 6 hours as needed, Hydrocodone 1 tab every 4 hours PRN - PRN or "as needed" did not have modifier for reason. Patient #9 - POC dated 03/15/2023 contained Melatonin 1 x day as needed, Loperamide 1 tab 4 times a day as needed, Ondansetron 1 tab every 4 hours as needed, Hydrocodone 1 tab every 6 hours PRN, Acetaminophen 650mg every 6 hours PRN, Guaifenesin ER 1 every 12 hours PRN - PRN or "as needed" did not have modifier for reason. Wound care to R upper arm 1x week and PRN no modifier for PRN. Patient #10 - POC dated 01/14/2023 contained Bisacodyl 1 x day PRN, Acetaminophen 325mg 2 tabs every 6 hours PRN - PRN did not have modifier for reason. Wound care to L forearm skin tear did not contain frequency. Patient #11 - Medication profile contained Lorazepam 0.5 mg every 2 hours PRN, Morphine .25mg every 2 hours as needed- PRN or "as needed" did not have modifier for reason. All corrected on site.

Upon client record review, 2 of 19 (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 - POC dated 03/29/2023 SC 2 x month effective 03/29/2023 - no visits made in March. Patient #5 - POC dated 03/10/2023 order for 04/13/2023 UA and dip at bedside - no documentation that this was completed. No order for Massage Therapy but made visit on 03/22/2023 and 04/14/2023.

Upon patient record review, 2 of 19 (Patient #6, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 - Aide care plan did not have the frequency for the task dressing, oral care, perineal care, shampoo or skin care. Corrected on site. Patient #14 - Aide care plan did not have the frequency for the task showering. Corrected on site.