Every finding on record at Holisticare Hospice, LLC

Upon personnel record review, 1 of 17 (Personnel #17) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #17: Upon review, there was no available evidence of emergency preparedness training for ST providing care

Upon patient record review 1 of 19 (Patient #8) 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 #8: Election statement effective date is 1/5/25 and signatures are 1/5/26. There was no evidence the comprehensive assessments were completed within 5 days after the election of hospice care.

Upon patient record review 1 of 19 (Patient #9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #9: Psychosocial assessment was not completed within 5 calendar days after election. The MSW entry was that visit was declined and was not completed by the RN.

Upon patient record review, 1 of 19 (Patient #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 #10: Hospice Rx Profile includes 2/16/26 Ativan 1 mg tab prn anxiety every 4 hours po. SNF Rx profile has 2/23/26 Ativan 0.5 mg tab every 4 hrs prn anxiety. (1 mg ended 2/23 on SNF orders) Facility Rx Profile has Acetaminophen supp rectally 650 mg prn, but Hospice Rx profile does not specify mg.

Upon patient record review, 6 of 19 (Patient #2, 3, 4, 5, 6, 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 #2: Patient has Depakote and Eliquis prescribed with no related problems, goals, interventions. Patient #3: Patient with heart disease and supporting dx of senile degeneration of the brain, dyspnea, and an order for oxygen 2 LPM prn. There are no respiratory or oxygen related problems, goals, interventions. Patient #4: Patient admitted with CVD and history of AF, PE, falls, with no related problems, goals, interventions including but not limited to no CV, respiratory, safety. Also patient has Xarelto and Plavix prescribed with no bleeding precautions. Patient #5: Patient has Eliquis prescribed and no related problems, goals, interventions. Patient #6: Patient has Xarelto and aspirin prescribed with no related problems, goals, interventions. Patient #10: Patient has Kepra for seizures, but no seizure precautions.

Upon patient record review, 4 of 19 (Patient #1, 2, 4, 6) 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: Initial visit frequency SC 2m2, 6 prn. There are too many PRN visits ordered. Patient #2: Initial visit frequency SC 2m3 and 6 prn. There are too many PRN visits ordered. Patient #4: Initial visit frequency SC 2m3 and 6 prn; MSW 1m3 and 6 prn. There are too many PRN visits ordered. Patient #6: Initial visit frequency SC 2m3 and 6 prn. There are too many PRN visits ordered.

Upon client record review, 2 of 19 (Patient #2, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: SOC 2/6/26, SC and MSW ordered 2mo3. SC 6 prn. MSW 3 prn. No documented SC visits after 2/6/26 visit. (only 1 visit Feb and no visit so far for March). IDG continued to identify SC frequency as 2x/month Patient #6: SOC 1/13/26. SC was ordered 2mo3 and 6 prn. No February visits documented by SC.

Upon patient record review, 5 of 19 (Patient #2, 3, 4, 5, 6) 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: Patient had Depakote and Eliquis prescribed with no related seizure and/or bleeding precautions included on the aide plan of care. Patient #3: Patient had PRN oxygen prescribed with no related safety precautions on the aide plan of care. Patient #4: Patient had Xarelto and Plavix prescribed with no related bleeding precautions on the aide plan of care. Patient #5: Patient had PRN oxygen prescribed with no related safety precautions. Eliquis prescribed with no related bleeding precautions on the aide plan of care. Patient #6: Patient had PRN oxygen prescribed with no related safety precautions. Xarelto and aspirin prescribed with no bleeding precautions on the aide plan of care.

Upon patient record review, 1 of 19 (Patient #8) 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 #8: Hospice Aide Care Plan assignment includes shower and shampoo weekly on Thursdays. Patient was showered 3/5/26 (Thurs), 3/6 (Fri), 3/8 (Sun), 3/12/26 (Thurs). Shampoo was performed 3/5 (Thurs), and 3/6 (Fri).

Upon personnel record review, 1 of 17 (Personnel #17) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #17: Upon review, there was no available evidence of orientation to hospice philosophy for ST providing care

Upon personnel record review, 1 of 17 (Personnel #17) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #17: Upon review, there was no available evidence of orientation to specific job requirements for ST providing care, as evidenced by signed job description and/or documentation of orientation.

Upon personnel record review, 1 of 17 (Personnel #17) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #17: Upon review, there was no available evidence that a skills competency assessment for ST providing care

Upon patient client record review, 2 of 19 (Patient #8, 12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #8: Election statement effective date is 1/5/25 and signatures are 1/5/26. Patient #12: Election date "to begin on...." space is left blank.

Upon patient client record review, 4 of 19 (Patient #4, 8, 12, 15) did not have evidence that each patient record contains Advance Directives. Patient #4, 12, 15: POC identifies patient as DNR. DNR/POLST has no MD/NP/PA signature. Patient #8: The POC identifies patient as a DNR. There is no DNR on file.

Upon patient client record review, 2 of 19 (Patient #3, 7) 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 #3: Document uploads include plan of care 12/2/25-03/01/25 for patient with same last name, different first name and different agency location under IDG updates. Upon staff interview, staff confirms not the same patient. Documents subsequently removed. Patient #7: Patient record inadvertently includes problems/precautions for gastrostomy when patient does not have one.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #3: Document uploads include plan of care 12/2/25-03/01/25 for patient with same last name, different first name and different agency location under IDG updates. Upon staff interview, staff confirms not the same patient. There is evidence records were not maintained in a confidential manner.

Upon patient record review, 9 of 19 (Patient #2, #3, #6, #7, #8. #10, #11, #12, #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. Patient #2-The patient was admitted on Oxygen. Oxygen is not on the medication profile. Patient #3-Polyethylene Glycol is listed on the medication profile as administer 1 packet po daily for constipation. A diluent is not included on the profile. (corrected on site) Patient #6-The medication profile includes Morphine 20 mg/ml 10 mg "so" (incorrect route) q2 (frequency incomplete) prn severe pain/sob. (corrected on site) Patient #7-On 04/12/23 the nurse documents the patient does not take MiraLax as ordered. Miralax is not included in the medication profile. (corrected on site) Patient #8-The medication profile includes 2 different dosages of prn Morphine without differentiation for administration. Morphine 20mg/ml 5 mg q2h po prn SOB/pain and Morphine 20mg/ml 10 mg q2h po prn SOB/pain. (corrected on site) Patient #10- The patient is on Oxygen and Oxygen is not listed on the medication profile. (corrected on site) Patient #11- The patient was admitted on Oxygen and Oxygen is not listed on the medication profile. (corrected on site) Patient #12-The medication profile includes MiraLax 17 gm 1 packet powder administer 1 packet qd prn constipation. A diluent is not on the profile. Novolog Flex pen is listed as 100u/ml 23 units before meals for Diabetes with sliding scale. A sliding scale is not listed on the profile. (corrected on site) Patient #13-The plan of care includes orders to instruct the patient on safe use of Oxygen. The Oxygen liter flow and frequency is not on the medication profile. (corrected on site)

Upon patient record review, 1 of 19 (Patient # 2) 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 #2- The patient was admitted on 03/07/23 and a bereavement assessment was not performed until 03/20/23.

Upon patient record review, 6 of 19 (Patient #9, #10, #11, #12, #13, #14) did not have evidence in the patient record that a complete comprehensive assessment is updated at least every 15 days. Patient #9- The nursing visit notes between 03/27/23 and 05/01/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the nursing notes only include vital signs, skin assessment and/or respiratory assessment. A complete assessment was not performed. Patient #10- The nursing visit notes between 03/29/23 and 04/19/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the nursing notes only include vital signs, skin assessment and/or neuro assessment. A complete assessment was not performed. Patient #11- The nursing visit notes between 03/31/23 and 04/27/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the nursing notes only include vital signs, skin assessment, pain and dementia assessment. A complete assessment was not performed. Patient #12- The nursing visit notes between 03/31/23 and 04/26/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the nursing notes only include vital signs and skin assessment/wound assessment. A complete assessment was not performed. Patient #13- The nursing visit notes between 03/13/23 and 04/27/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the visits are routine visits which chart vital signs and 3-4 system reviews by exception. A comprehensive assessment is not on record during this time frame. Patient #14-The nursing visit notes between 03/09/23 to 04/25/23 do not evidence a complete comprehensive head to toe assessment was performed. Each of the visits are routine visits which chart vital signs and 3-4 system reviews. (Charting by exception). A comprehensive assessment is not on record during this time frame.

Upon patient record review, 9 of 19 (Patient #2, #3, #6, #7, #8, #10, #11, #12, #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 specific orders for all medications and treatments. Patient #2-The patient was admitted on Oxygen. Oxygen is not on the plan of care. (Corrected on site) Patient #3-Polyethylene Glycol is listed on the plan of care as administer 1 packet po daily for constipation. A diluent is not included in the orders. (corrected on site) Patient #6-The plan of care includes Morphine 20 mg/ml 10 mg "so" (incorrect route) q2 (frequency incomplete) prn severe pain/sob. (corrected on site) Patient #7-On 04/12/23 the nurse documents the patient does not take MiraLax as ordered. MiraLax is not included in the plan of care. (corrected on site) Patient #8-The plan of care includes 2 different dosages of prn Morphine without differentiation for administration. Morphine 20mg/ml 5 mg q2h po prn SOB/pain and Morphine 20mg/ml 10 mg q2h po prn SOB/pain. (corrected on site) Patient #10- On 04/13/23 the nurse documents the patient is on Oxygen. Oxygen liter flow orders are not included in the plan of care. (corrected on site) Patient #11- The patient was admitted on Oxygen and Oxygen liter flow orders are not included in the plan of care. The patient was also admitted with an ostomy and the plan of care does not address management of the Ostomy. (corrected on site) Patient #12- The plan of care includes MiraLax 17 gm 1 packet powder administer 1 packet qd prn constipation. A diluent is not on the profile. Novolog Flex pen is listed as 100u/ml 23 units before meals for Diabetes with sliding scale. A sliding scale is not listed on the plan of care. The patient was admitted with a suprapubic catheter. The plan of care does not address management of the catheter and catheter site. The plan of care includes orders to cleanse/pack sacral wound with Aquacel. The cleansing agent, dressing cover and frequency of dressing change is not included in the order. (corrected on site) Patient #13-The plan of care includes orders to instruct the patient on safe use of Oxygen. The Oxygen liter flow and frequency is not on the plan of care. (corrected on site)

Upon patient record review, 7 of 19 (Patient #1, #2, #8, #11, #12, #13, #14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1-The IDG/revised plan of care 04/03/23 and 04/18/23 does not include nursing documentation to notate the patient progress towards goals. The IDG documentation only includes Social Worker and Chaplain documentation to evidence progress towards outcomes. Patient #2-The IDG/revised plans of care 03/08/23 -04/20/23 do not address findings from the patient's comprehensive assessment and/or progress towards goals. Each of the notes document nursing will continue to monitor for decline and collaborate with family. The Social Worker documentation only includes SW will build rapport and provide psychosocial support. Patient #8- The IDG/revised plan of care 04/12/23 and 04/27/23 does not address findings from the patient's comprehensive assessment and/or progress towards goals. Nursing documentation on 04/12/23 only documents nursing will develop a trusting relationship as patient is a new admission with Cancer. The 04/27/23 note only documents nurse will monitor patients skin integrity due to tumor left groin. 04/13/23 and 04/27/23 social worker documentation states SW will be available for support as needed and continue to visit/develop rapport. Patient #11-The patient was admitted on 03/15/23 . The 03/27/23 first IDG/revised plan of care does not include findings from the patients initial assessment. IDG notes 03/27/23-04/25/23 do not address progress towards goals. Each of the notes document SW will continue to provide support and companionship as patient declines. Patient #12- The patient was admitted on 03/30/23 . The 03/31/23 first IDG/revised plan of care does not include findings from the patients initial assessment. The IDG note on 03/31/23 only documents the plan is to pack the patients stage 3 sacral wound. IDG note on 4/13/23 does not address progress towards goals. The note only documents education on wound provided. Patient #13- The patient was admitted on 03/12/23 . Each of the IDG notes/revised plan of care 03/15-04/12/23 do not address issues identified in the comprehensive assessments related to the patients physical, spiritual and psychosocial needs. Each of the nursing IDG notes document the patients care planning needs and medications were reviewed. The Social worker notes document SW to provide support and companionship and Spiritual visit notes document Chaplain will monitor and provide spiritual support. Patient #14 -The patient was admitted on 03/8/23. The 3/16/23 IDG note does not address the findings of the comprehensive assessment. The note only documents discussed use of incentive spirometry. Subsequent IDG notes do not address nursing progress towards goals.

Upon patient record review, 5 of 19 (Patient #2, #3, #4, #11, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2- On 03/31/23 the nurse documented administering a mineral oil enema. The record does not include orders for an enema. (corrected on site) Patient #3- Social Worker is ordered to visit once monthly. Two routine visits were documented for March on 03/03/23 and 03/24/23. Spiritual Care is to visit once monthly. Two routine visits were documented for March on 03/17/23 and 03/23/23. Patient #4- Nursing is ordered to visit twice weekly. Nursing visits were provided once weekly between 02/07/23 and 04/20/23. There no documented missed visits are on record. (corrected on site) Patient #11- The Chaplain is ordered to visit once monthly. Visits were performed 04/11/23 and 04/22/23 The visits were routine visits. Patient #13-Effective 03/12/23 the Chaplain is ordered to visit monthly. Routine visits were performed on 3/15 and 3/22 (twice monthly) and 4/10, 4/11, 4/21(three times monthly).

Upon patient record review, 1 of 19 (Patient #15) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #15- The Bereavement plan of care does not include interventions. The record indicates the bereavement coordinator attempted a call on 10/21/22 the day following the patients death. A message was left to give a detailed reason for the call with an invitation to call back if there are any needs. There are no further documented attempts to contact the family on record.

Upon patient record review 6 of 19 (Patient #2, #5, #7, #9, #11, #14) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care. Patient #2- The Aide is ordered to visit 5 times weekly. Between 3/12/23 and 4/27/23 there are only 5 total visits documented on record which were performed 3/12/23, 3/16/23, 3/30/23, 4/13/23, and 4/27/23. There is no documentation regarding the missed visits. The Aide was also ordered to perform a tub/shower and lotion patient three times weekly. On 3/12/23, 3/30/23, 4/13/23 and 04/27/23 the Aide documented not required at today's visit. Patient #5- The Aide Care Plan includes the assignment to provide a shampoo weekly on Mondays. On Monday 04/24/23 the Aide documented not required at todays visit. Patient #7- The Aide is ordered to visit twice weekly. The week of 03/26/23-04/01/23 the patient was visited once on 04/01/23. The week of 04/02/23-04/08/23 the patient was visited once on 04/06/23. There is no documentation on record regarding the missed visits. Patient #9-The Aide was ordered to visit three times weekly effective 03/07/23. The week of 03/07/23 the record does not contain Aide visits. There are no aide visits on record following 04/05/23. There is no documentation regarding missed visits or orders to discontinue the aide (corrected on site). Patient #11- The Aide is ordered to visit four times weekly. The week of 04/02-04/08/23 the aide visited once on 04/02/23. The week of 04/23/23-04/29/23 the aide visited three times on 04/23/23, 04/26, and 04/29/23. There is no documentation regarding the missed visits. Patient #14-The Aide is ordered to visit three times weekly effective 03/08/23. The Aide provided the first visit on on 3/30/23. The week beginning 04/02/23 1 visit was provided on 04/03/23. The week 04/09/23 2 visits were provided on 04/11/23 and 04/14/23. The week of 04/16/23 2 visits were provided on 04/17/23 and 04/21/23. There is no documentation on record regarding the missed visits.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the hospice provided the following information to the SNF: Patient #3- The record review and visit to the facility did not evidence the facility was provided: •The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient •Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient (corrected on site )