Every finding on record at Legacy Care Hospice, Inc.

Upon patient record review, 7 of 14 (Patient # 1,3,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,3,6,7,8,9 & 10: Imminently dying was not assessed on the admission comprehensive assessment or addressed in visit summary.

Upon patient record review, 4 of 14 (Patient #1,4,5,8) 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 Record contains order(s) for Hydrocortisone 1 gram topically 3 times daily as needed for itching and does not indicate a site of application/ The Medication Record contains order(s) for Acetaminophen 325 2 tabs every 6 hours as needed for pain/fever and Acetaminophen 650mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, Medication Record updated. Patient 4: The Medication Record contains order(s) for Hydrocodone Bitarate-Acetaminophen 5/325 schedule daily, Hydrocodone Bitarate-Acetaminophen 5/325 twice daily prn and Acetaminophen 650 mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, Medication Record updated. Patient 5: The Medication Record contains orders for Acetaminophen 500mg scheduled every 4 hours for pain, Hydrocodone Bitarate-Acetaminophen 10/325 every 6 hours as needed for pain and Acetaminophen 650 mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, Medication Record updated. Patient 8: The Medication Record contains orders for Acetaminophen 325 2 tabs every 6 hours as needed for pain/fever and Acetaminophen 650mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, Medication Record updated.

Upon patient record review, 2 of 14 (Patient #5,8) 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 5: POC dated 10/11/25 does not include interventions and goals for documented stage 4 ulcer. Patient 8: Patient most recent POC contains orders for Aspirin without a risk for bleeding care plan with appropriate interventions and goals. In addition, POC does not include skin integrity care plan with appropriate interventions and goals for use of barrier creams. Corrected on site, POC updated.

Upon patient record review, 4 of 14 (Patient #1,4,5,8) 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 1: Current POC contains order(s) for Hydrocortisone 1 gram topically 3 times daily as needed for itching- does not indicate a site of application. Current POC contains orders for Acetaminophen 325 2 tabs every 6 hours as needed for pain/fever and Acetaminophen 650mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily from all sources of Acetaminophen. Corrected on site, POC updated. Patient 4: Current POC contains order(s) for Hydrocodone Bitarate-Acetaminophen 5/325 schedule daily, Hydrocodone Bitarate-Acetaminophen 5/325 twice daily prn and Acetaminophen 650 mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, POC updated. Patient 5: The current POC contains order(s) for Acetaminophen 500mg scheduled every 4 hours for pain, Hydrocodone Bitarate-Acetaminophen 10/325 every 6 hours as needed for pain and Acetaminophen 650 mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen. Corrected on site, POC updated. Patient 8: Current POC contains orders for Acetaminophen 325 2 tabs every 6 hours as needed for pain/fever and Acetaminophen 650mg rectal supp every 4 hours as needed for temp/pain twice daily. There is no directive not to exceed 4g daily for Acetaminophen; Current POC does not include skin integrity care plan with appropriate interventions and goals for use of barrier creams. Corrected on site, POC updated.

Upon patient record review, 1 of 14 (Patient #9) 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 9: Current POC does not include skin integrity care plan with appropriate interventions and goals for use of barrier creams (A&D & Calmoseptine). Corrected on site, POC updated.

Upon patient record review, 6 of 14 (Patient #2,3,4,6,9,10) 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 current Aide POC has empty collection bag and turn and reposition without frequency. Corrected on site, POC updated. Patient 3: The current Aide POC does not include frequency for turn and reposition & change patient linens without a frequency indicated. Corrected on site, POC updated. Patient 4: The current Aide POC does not include frequency for feeding assistance & encourage fluids as tolerated if not contraindicated. Corrected on site, POC updated. Patient 6: The current Aide POC does not include a frequency for empty collection bag, turn and reposition, feeding assist, encourage fluids as tolerated if not contraindicated or change patient linens. Corrected on site, POC updated. Patient 9: The current Aide POC does not include a frequency for encourage fluids as tolerated if not contraindicated or change patient linens. Corrected on site, POC updated. Patient 10: The current Aide POC does not include a frequency for dressing in pajamas/gown and encourage fluids as tolerated if not contraindicated. Corrected on site, POC updated.

Upon patient record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 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 Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: The medical record contains nursing documentation identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patients 1, 2, 3 and 4 Corrected on site.

Upon patient record review, 3 of 11 (Patient #6, 7, 11) 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 SOC was 1/19/22. The initial bereavement assessment was completed on 3/15/22. Patient 7: There was no evidence of an initial bereavement assessment having been completed. Patient 11: There was no evidence of an initial bereavement assessment having been completed.

Upon patient record review, 9 of 11 (Patient #1, 3, 4, 5, 7, 8, 9, 10, 11) 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, 3, 4, 5, 7, 8, 9, 10, 11: Upon medical record review, the medical record contains PRN nursing visits without a PRN frequency. Patients 1, 3 and 4 corrected on Site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: Dirty equipment was cleaned then put back on dirty side of barrier. Clinician did not use hand sanitizer after removing gloves and before going into bag after providing patient care.

Upon patient record review 4 of 11 (Patient #1, 4, 5, 6) 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 Patient 1: The medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 10/14/22. Corrected on Site. Patient 4: The medical record contains ordered aide frequency of three times weekly. There was no evidence of a visit weeks of 10/2/22 and 10/16/22. Corrected on Site. Patient 5: The medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 8/7/22. Patient 6: The medical record contains ordered aide frequency of twice weekly. There was evidence of 3 visits per week starting on 3/6/2022.

Upon patient record review, 2 of 11 (Patient #1, 5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items on 10/14/22. There was no evidence that the representative received the form. Patient 5: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items on 8/10/22. There was no evidence that the representative received the form.