Every finding on record at Holy Redeemer Hospice

Upon patient record review, 3 of 19 (Patient #2, 3, 6) 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 admitted with indwelling Foley catheter. No related problems, goals and interventions. Patient #3: Patient with history of falls including preadmission fall resulting in fractured humerus. No initial problems, goals and interventions for safety precautions and also skin tear leg with no initial problems, goals interventions related to wound/skin integrity Patient #6: Patient admitted with Eliquis prescribed and no problems, goals, interventions related to bleeding precautions.

Upon patient record review, 2 of 19 (Patient #3, 4) 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 #3: Patient admitted 11/28/25 with skin tear RLL. Wound orders obtained 12/5/26. No update to problems, goals, interventions to include wound/treatment. Patient #4: Patient admitted 11/27/25. Physician orders for wound care buttocks 1/18/26 and coccyx 1/21/26. No updates to problems, goals, interventions.

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: SOC 9/30/25. suprapubic - with last changed documented as 9/25/25 and physician order to change q4-6 weeks. 3/2/26 note says catheter last changed 1/28/26 but 1/28/26 note does not include documentation related to change. No documented evidence to verify catheter changes in accordance with physician order.

Upon patient record review 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #9: Initial RN assessment SOC 2/26/26. RN documented patient open to chaplain services. No evidence chaplain visit provided or declined. Nursing problems include need for chaplain-hospice.

Upon home visit(s) observation 1 of 3, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Upon observation, the hospice aide did not change gloves after completing bath and disposing of incontinent pad.

Upon patient record review, 3 of 19 (Patient #2, 6, 12) 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 with indwelling Foley catheter. Aide Care Plans do not include reference to Foley. Patient #6: Patient with Eliquis prescribed and Aide Care Plan do not include related bleeding precautions. Patient #12: Patient with nephrostomy tube/drainage bag and Aide Care Plan do not include related alert/reference.

Upon patient client record review, 7 of 19 (Patient #6, 7, 8, 11, 12, 13, 14) 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 #6: SN visit 10/24/25 RN documented gross hematuria. MD contacted. RN did not reference/acknowledge that patient was on Eliquis at the time. Patient was treated for UTI and hematuria resolved. Patient #7: Initial RN SOC assessments includes goals not met: Foley catheter patent (requires more time), but GU includes incontinence only and no reference to Foley. Interview with staff verifies patient did/does not have indwelling catheter. Patient #8: Initial RN SOC assessment includes goals met: Foley patent, understanding of Foley catheter care. GU includes incontinence only and no reference to Foley. Interview with staff verifies patient did/does not have indwelling catheter. Patient #11 Initial RN SOC assessment includes goals met: Foley catheter patent, understanding of Foley catheter care. No other reference to Foley catheter. Interview with staff verifies patient did/does not have indwelling catheter. Patient #12: Page 2 of Consent form states projected disciplines and visit frequencies... "At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, Home Health Aide eval, Dietician eval, ST eval..... " Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available. Patient #13: Admission Consent form Page 2 states projected disciplines and visit frequencies: "At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, HA eval, dietician eval, ST eval..." Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available. The 2/7/26 initial RN SOC assessment note lists last catheter change as 2/2/26. SN note 3/2/26 states patient catheter last changed 1/28/26. 3/4/26 note says catheter last changed 3/3/26, but there is no note for that date. 3/2 note says catheter will not be changed. Patient #14: Admission Consent form Page 2 states projected disciplines and visit frequencies: At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, HA eval, dietician eval, ST eval..." Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available.

Upon patient record review, 10 of 19 (Patient #1, #2, #3, #4, #6, #7, #8, #9, #12, #14) 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: The medication profile listed cephalexin capsule 500 mg 4x/day ordered 07/22/2022 and cephalexin tablets 500 mg 4x/day ordered 04/28/2023 however, these are no longer active per agency. In addition, on 01/30/2023 listed mupirocin topical daily to L knee wound that was no longer being used however, it was not discontinued. COS Patient #2: The medication profile listed on 04/18/2023 fentanyl 75mcg transdermal patch every 72 hours without evidence of directions for specific location(s) for placement. In addition, on 04/21/23 lidocaine topical 5% ointment three times a day and 04/18/2023 lidocaine patch 5% to affected area without evidence of specific location for application. On 05/01/2023, triple antibiotic ointment twice a day PRN without evidence of specific location for application. COS Patient #3: The medication profile listed on 04/17/2023 cipro 250 mg twice a day for 7 days and on 04/24/2023 doxycycline 100mg twice a day for 5 days however, both remained an active. In addition, on 02/22/2023 Lumigan and Timoptic eye drops without evidence of which eye(s) for application. On 02/22/2023, listed morphine 20mg/mL 0.25-1.0mL every 3 hours PRN for SOB and pain however, there was no evidence of specific directions for dosing needs/requirement. COS Patient #4: The medication profile listed on 02/24/2023 orders for acetaminophen 325mg tablets, 2 tabs every 4 hours PRN pain and 650mg suppository 1 every 6 hours PRN fever however, there was no evidence of maximum allowable dose. COS Patient #6: The medication profile listed on 01/31/2023 polyethylene glycol 17gm oral powder however, there was no evidence of mixing directions. In addition, on 01/19/2023 triple antibiotic ointment twice a day without evidence of specific area for application. COS Patient #7: The medication profile listed all medications twice with the exception of loperamide and naproxen. COS Patient #8: The medication profile listed on 01/23/2023 A&D ointment, DemaCerin ointment, lidocaine topical, and zinc oxide topical as part of magic butt cream without evidence of specific application area. In addition, all ointments were listed as twice a day with the exception of lidocaine which was listed as twice a day PRN. On 12/07/2022 the vitamin B12 injection did not contain evidence of specific location for injection. COS Patient #9: The medication profile listed on 03/27/2023 acetaminophen 325mg tablets, 2 tablets every 6 hours PRN pain and acetaminophen 650mg rectal suppository 1 every 8 hours PRN pain/fever however, there was no evidence of maximum allowable dose. In addition, 03/27 morphine 0.25-1.0mL every 3 hours PRN pain or SOB without evidence of further dosing directions. COS Patient #12: The medication profile listed on 01/25/2023 and 04/08 cipro x 7 days each time however, this was still active. In addition, lidocaine and Neosporin ointment without evidence of specific area for application. COS Patient #14: The medication profile listed on 10/01/2022 Neosporin and on 11/01/2022 proctozone ointments without evidence of specific area for application. COS

Upon patient record review, 1 of 19 (Patient #8) 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 #8: The patient admitted 12/07/2022 however, there was no evidence that a bereavement assessment was completed.

Upon patient record review, 8 of 19 (Patient 1, 3, 4, 5, 6, 7, 8, 14) 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 #1: Upon admission 07/14/2022 problems/interventions/goals for declining status/imminence were added to plan of care and remained however, documentation does not indicate patient is imminent and confirmed with agency. Patient #3: Patient was treated in April for a UTI and URI however, the plan of care did not contain evidence of infection related problems/interventions/goals. Patient #4: The patient had oxygen upon admission however, the plan of care did not have evidence of oxygen precautions. The nurse documented on 04/18/2023 patient was having nausea/vomiting and anxiety and recommended using PRN meds however, the plan of care did not contain evidence of related problems/interventions/goals. COS Patient #5: Upon admission 06/24/2022 problems/interventions/goals for declining status/imminence were added to plan of care and remained however, documentation does not indicate patient is imminent and confirmed with agency. Patient #6: The IDG note 04/11/2023 indicated patient had a post head tumor with drainage that was being treated with and antibiotic however, the plan of care did not contain evidence of skin integrity related problems/interventions/goals. The IDG note 03/30/2023 had flu with nausea and vomiting symptoms however, the plan of care did not contain evidence of related problems/interventions/goals and on 04/20/2023 indicated patient had gout that was being treated however, the plan of care did not contain evidence of pain related problems/interventions/goals. COS for 04/20 Patient #7: The IDG note on 03/30/2023 noted patient having nausea/vomiting due to flu however, there was no evidence plan of care had been updated with problems/interventions/goals. In addition, orders written for gout and noted in 04/11 IDG that patient was having gout pain in R great toe and again on 04/20 L great toe and 3rd toe (nurse's note 4/20) however, there were no problems/interventions/goals related to pain. COS Patient #8: Upon admission 12/07/2022 problems/interventions/goals for declining status/imminence were added to plan of care and remained however, documentation does not indicate patient is imminent and confirmed with agency. In addition, an order on 03/20/2023 to treat R heel wound however, the plan of care did not contain evidence of skin integrity or wound related problems/interventions/goals. COS Patient noted on 03/30 IDG note patient had seizure activity and was unable to swallow however, there was no evidence of aspiration precautions. COS Patient #14: The patient admitted on 08/21/2022 with dysphagia following a CVA however, there was no evidence of neurological problems/interventions/goals. COS

Upon patient record review, 10 of 19 (Patient #1, #2, #3, #4, #6, #7, #8, #9, #12, #14) 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: The order for cephalexin capsule 500 mg 4x/day ordered 07/22/2022 and cephalexin tablets 500 mg 4x/day ordered 04/28/2023 however, these were no longer active. In addition, there was an order from 01/30/2023 for mupirocin @% topical daily to L knee wound that was no longer being used however, it was not discontinued. COS Patient #2: The order on 04/18/2023 fentanyl 75mcg transdermal patch every 72 hours without evidence of directions for specific location(s) for placement. In addition, on 04/21/23 lidocaine topical 5% ointment three times a day and 04/18/2023 lidocaine patch 5% to affected area without evidence of specific location for application. On 05/01/2023, triple antibiotic ointment twice a day PRN without evidence of specific location for application. COS Patient #3: The order on 04/17/2023 cipro 250 mg twice a day for 7 days and on 04/24/2023 doxycycline 100mg twice a day for 5 days however, both remained an active order. In addition, on 02/22/2023 Lumigan and Timoptic eye drops without evidence of which eye(s) for application. On 02/22/2023, an order for morphine 20mg/mL 0.25-1.0mL every 3 hours PRN for SOB and pain however, there was no evidence of specific directions for dosing needs/requirement. COS Patient #4: The order on 02/24/2023 orders for acetaminophen 325mg tablets, 2 tabs every 4 hours PRN pain and 650mg suppository 1 every 6 hours PRN fever however, there was no evidence of maximum allowable dose. In addition, the order on 04/20/2023 to cleanse L elbow with NSS, apply 4x4 COPA foam border pad was still active but documentation indicated wound closed 04/26/2023. COS Patient #6: The order on 01/31/2023 polyethylene glycol 17gm oral powder however, there was no evidence of mixing directions. In addition, on 01/19/2023 triple antibiotic ointment twice a day without evidence of specific area for application. COS Patient #7: There were duplicate orders for all medications with the exception of loperamide and naproxen. COS Patient #8: The order on 01/23/2023 A&D ointment, DemaCerin ointment, lidocaine topical, and zinc oxide topical as part of magic butt cream without evidence of specific application area. In addition, all ointments were listed as twice a day with the exception of lidocaine which was listed as twice a day PRN. On 12/07/2022 the vitamin B12 injection did not contain evidence of specific location for injection. COS Patient #9: The orders on 03/27/2023 acetaminophen 325mg tablets, 2 tablets every 6 hours PRN pain and acetaminophen 650mg rectal suppository 1 every 8 hours PRN pain/fever however, there was no evidence of maximum allowable dose. In addition, 03/27 order for morphine 0.25-1.0mL every 3 hours PRN pain or SOB without evidence of further dosing directions. COS Patient #12: The orders on 01/25/2023 and 04/08 cipro x 7 days each time however, this was still active. In addition, lidocaine and Neosporin ointment orders without evidence of specific area for application. COS Patient #14: The orders on 10/01/2022 Neosporin and on 11/01/2022 proctozone ointments without evidence of specific area for application. COS

Upon patient record review, 4 of 19 (Patient #2, #3, #9, #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 equipment and supply needs. Patient #2: The nurse note on 05/01/2023 noted patient was using a gel overlay however, there was no evidence of this on the plan of care. COS Patient #3: The medication list indicated oxygen order however, there was no evidence of oxygen equipment on plan of care. COS Patient #9: Upon observation during home visit it was noted patient had a low air loss mattress however, this was not included on plan of care. COS Patient #13: The medication list indicated oxygen order however, there was no evidence of oxygen equipment on plan of care. COS

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #5: The election of benefits indicated patient selected Dr. SM as attending however, there was no evidence of collaboration with attending to review the plan of care.

Upon client record review, 8 of 19 (Patient #1, #4, #5, #6, #7, #8, #13, #14) 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 04/19/2023, the nurse documentation indicated that patient had redness, irritation, and drainage of right foot and "cleaned and applied 4x4 gauze" however, there was no evidence of orders for treatment. On 04/28 and 04/30/2023, nurse documentation indicated wound care provided "per orders" but details were not included on nursing note. The nursing visit frequency on 03/12/2023 was 3W8, 1W1 and on 03/26/2023 was 2W1, 3W5, and 1W1 however, the visits performed every W and F were noted to be PRN visits and noted in nursing notes that it was a routine visit for wound care. Patient #4: The nurse visit frequency on 04/23/2023 was 4W1, 2W3, 1W1 however, the week of 04/23 there was only evidence of 3 visits completed. COS In addition, the nurse documented on 04/18 that patient had a bruise and blister on L elbow which popped during visit and nurse "cleansed with NSS and applied 4x4 COPA pad" however, the order for treatment was dated 04/20/2023. Patient #5: The nurse visit frequency on 03/26/2023 was 1 every 2W2, 1W2 and visit the week of 03/26 was cancelled by patient and then patient was seen 04/05, 04/12, and 04/18/2023. Patient #6: The nurse visit frequency on 02/12/2023 was 2W5, 3W1, 2W2 however, there was only evidence of 1 visit the week of 03/19. In addition, the social work and spiritual care visit frequency ordered 01/10/2023 effective 01/08 was 1M1, 1-2M, 1M1 however, the month of January the chaplain visited 01/10 and 01/24 and social work visited on 01/10 and 01/25 and in April there was no evidence of visit by social work. Patient #7: The nurse visit frequency 03/23/2023 was 2 every 2W2, 2W7 and the visit the week of 03/19 was cancelled however, the week of 03/26 and 04/02 there was evidence of two visits each week. In addition, the social work visit frequency on 02/19/2023 was 1 every3W3, 1 every 2W2 and visits were performed 02/13, 03/14, and 04/14. There was an order on 03/19 for 0 visits and on 03/20 for duplicate visit;visits in range, these were in the order description and not clear on the frequency. Patient #8: The nurse visit frequency on 04/02/2023 was 1W1, 1 every 4W4 however, there was no evidence of visit the week of 04/02. In addition, nurse documentation on 04/27 PRN visit indicated wound care provided "per orders" but details were not included on nursing note. Patient #13: Several nurse documentation notes patient had nephrostomy tubes and an ostomy that was being drained and dressing changes, there was no evidence for treatment orders. COS Patient #14: On 04/27/2023 and 05/04, the nurse documentation indicated wound care provided "per orders" but details were not included on nursing note.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient #3: The patient was treated for upper respiratory infection however, there was no evidence of this variance being reported or investigated. COS

Upon patient record review 3 of 19 (Patient #3, #9, #10) 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 #3: The aide visits were discontinued on 04/19/2023 however, visits continued each day 04/17-04/21 and 04/24-04/28/2023. In addition, the aide plan of care indicated linens to be changed weekly however, the aide note indicated linens changed 04/17, 04/18, 04/19, 04/20, 04/21, 04/24, 04/26, and 04/28. Patient #9: The aide visit frequency 0n 03/27/2023 was 4W1, 5W11, 2W1 however, there was only evidence of 2 visits the week of 03/26, and 3 visits the weeks of 04/02, 04/09, and 04/23. In addition, the aide plan of care indicated to change linens weekly however, the aide note indicated linens changed 04/18, 04/19, 04/20, 04/26, 04/27, and 04/28. Patient #10: The aide plan of care indicated to shampoo and change linens weekly, however the aide note indicated shampoo and linens changed on 04/17 and 04/21. In addition, upon home visit with aide the aide indicated the dressing for patient buttocks was changed by aide after bathing patient however, this was not on the plan of care. COS

Upon patient client record review, 1 of 19 (Patient #5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #5: The election of benefits indicated patient selected Dr. SM as attending however, there was no evidence of a signed certification from attending.

Upon patient client record review, 6 of 19 (Patient #1, #2, #7, #11, #12, #14) did not have evidence that each patient record contains Advance Directives. Patient #1: The plan of care listed DNR as awaiting physician signature however, there was evidence of signed DNR in patient file. COS Patient #2: The plan of care listed DNR as awaiting physician signature however, there was evidence of signed DNR in patient file. COS Patient #7: The plan of care indicated patient was a DNR however, there was no evidence of copy of advance directive in chart. COS Patient #11: The plan of care listed DNR as awaiting physician signature however, there was evidence of signed DNR in patient file. COS Patient #12: The plan of care listed DNR as awaiting physician signature since admission 04/28/2022 however, there was no evidence of signed DNR in patient file. COS Patient #14: The plan of care listed DNR as awaiting physician signature since admission 04/28/2022 however, there was no evidence of signed DNR in patient file. COS

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. COS

Upon client record review, 1 of 19 (Patient #9) 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 #9: The patient was ordered on Santyl for wounds on buttocks and sacrum on 04/24/2023 and nurse documentation indicated still active however, there was no evidence the plan of care was updated to include skin integrity or wound problems/interventions/goals. COS

Upon home visit, 1 of 19 (Patient #9) did not have evidence that the hospice provided the following information to the SNF: • Physician certification and recertification of the terminal illness specific to each patient COS