Every finding on record at Hillrise Home Management LLC

Upon patient record review, 3 of 14 (Patients #1,#2,#3) 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: Gabapentin 100mg, Vitamin D Supplement, Tramadol/Acetaminophen 37.5mg/325mg, Loperamide 2mg and Probiotic Supplement were listed on agency medication profile. During reconciliation of medications at facility these were not included in patients medication box. Agency D/C' d these medications during IDG. Corrected on site. Patient #2 and #3: These patients had Miralax 17 gm powder listed on medication profile. This medication did not include diluent. Corrected on site.

Upon patient record review, 1 of 14 (Patient #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 #6: The initial bereavement risk assessment was not completed timely. The assessment was performed on 9/3/24. The patient was admitted on 8/22/24.

Upon patient record review, 2 of 14 (Patients #13,#14) 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 Patients #13, #14: Bereavement visit frequency indicated PRN only for Home Visit. This frequency did not include a baseline visit frequency for the Bereavement Coordinator. Order clarification with IDG during survey. Corrected on site.

Upon patient record review, 3 of 14 (Patients #1, #2, #3) 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: Gabapentin 100mg, Vitamin D Supplement, Tramadol/Acetaminophen 37.5mg/325mg, Loperamide 2mg and Probiotic Supplement were listed on agency plan of care. During reconciliation of medications at facility these were not included in patients medication box. Agency D/C' d these medications during IDG. Corrected on site. Patient #2 and #3: These patients had Miralax 17 gm powder listed on plan of care. This medication did not include diluent. Corrected on site.

Upon patient record review, 14 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1 through #14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Agency had updated forms to include this information during survey for all future admissions. COS.

Upon observation there was not 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. The agency Volunteer Activity tracking form was left blank where percentage of hours are tabulated. Agency is at greater than 5% total patient hours. Corrected on site.

Upon patient record review, 2 of 14 (Patients #11, #12) did not have evidence that the discharge summary includes all required information. Patients #11, #12: The Discharge Summary did not have evidence the patients plan of care or attending physician name (NPI number only) were included in DC summary as required.

Upon patient record review, 1 of 11 (Patient #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #8 - The record indicated Albuterol Sulfate 1 amp PRN as needed for pulmonary congestion and Meclizine HCL 25mg 1 tab PRN/as needed for vertigo on the medication list. There was no evidence of the frequency of the PRN. COS

Upon patient record review, 1 of 11 (Patient #7) 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 #7 - The record indicated the social worker visit order to be 1x/month plus PRN. There was no frequency for the PRN. COS

Upon patient record review, 1 of 11 (Patient #8) 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 #8 - The record indicated an order for Albuterol Sulfate 1 amp PRN as needed for pulmonary congestion and Meclizine HCL 25mg 1 tab PRN/as needed for vertigo. There was no evidence of the frequency of the PRN. COS

Upon patient record review, 2 of 11 (Patient #1,2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,2 - Social worker visit notes dated 11/12/20 and 12/31/20 and chaplain visit notes dated 11/18/20 and 12/31/20 indicated that the visits were done by telehealth. There was no evidence of telehealth visits on the plan of care.

Upon patient record review, 4 of 9 applicable (Patient #2,3,6,8) 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 aide care plan included "pain rating q visit. Notify RN of changes if pain >3". The patient had Alzheimer's Disease as the primary terminal diagnosis. The nurse documentation on the 9/7/21 indicated the patient was unable to give a pain rating based on "patient responds to name, otherwise disorientated, unable to communicate meaningfully, uses word salad through the visit." COS Patient #3 - The aide care plan included "change linens per patient request" and "pain rating q visit. Notify RN of changes if pain > 3." The patient had a terminal diagnosis of senile degeneration of the brain. The nurse documentation indicated the patient is unable to give a pain rating or give direction about linen change based on "remains in general state of confusion". COS Patient #6 - The aide care plan included "pain rating q visit. Notify RN of changes if pain >4." The nurse note dated 8/26/21 indicated the patient was unable to give a pain rating based on "limited speech mostly word salad." COS Patient #8 - The aide Care plan included shower chair or complete bed bath "per patient's tolerance", with no indication if the patient is cognitively and functionally able to decide. Aide is unable to make determination. COS

Upon patient record review 2 of 9 applicable (Patient #6,9) 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 #6 - The record indicated an aide missed visit on 9/13/21 and there was no documentation evidence that it was reported to RNCM. COS Patient #9 - The record indicated an aide missed visit on 6/19/21 and there is no documentation evidence it was reported to RNCM.

Upon patient record review, 6 of 11 (Patient #1,2,3,7,9,10) did not have evidence that each patient record contains evidence that the patient/family were given the option to elect to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs. If the patient/family elected to receive the information there was not evidence in the record it was given to them. Patient 1,2,3,7,10 -The records did not include evidence that the patients/families were given the option to elect to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs information. #1 COS Patient #9 - The records indicated that the patient/family elected to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs information. There was no evidence in the record that the Patient Notification of Hospice Non-Covered Items, Services and Drugs information was given.