Every finding on record at Legacy Hospice LLC

Upon patient record review, 1 of 23 (Patient # 9) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 9: 12/4/25 SN visit RN documents pain score 10 and Dyspnea score 5 on 1-10 scale. MD notified and aide reports to RN patient’s refusal of all care due to pain. Oxycodone discontinued and Fentanyl patch ordered. No follow up until next visit 12/8/25 RN documents patient “did not understand use of patches and had not started Fentanyl. Continues with uncontrolled pain.” RN visits scheduled weekly. Upon home visit 12/17/2025, patient reports pain “9” on 1-10 scale and “ran out of pain medication 2-3 days ago.” RN confirms that patient’s PRN medication is expected to be delivered later today. During home visit, patient states "I haven't been without pain since 2006." Patient lives alone and has no caregiver. COS after home visit, MD updated and new order obtained to increase Fentanyl patch to 75 mcg every 72 hours and agency plans a supervisory visit with RN to assess effectiveness.

Upon patient record review, 11 of 23 (Patient # 1, 2, 3, 4, 5, 7, 9, 10, 12, 13 and 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: Patient 1: The agency medication profile on 10/14/25 contains orders for Acetaminophen, Milk of Magnesium not on facility medication profile and SNF medication profile contains orders for Docusate, Donepezil, Levothyroxine, Multivitamin, and Zoloft not present on agency medication profile. COS with updated medication profile. Patient 2: The agency medication profile on 12/11/25 contains orders for Prochlorperazine and Levofloxacin not present at SNF and there is no evidence of facility medications listed including Acetaminophen and multi-vitamin. COS with updated medication profile. Patient 3: The POC on 10/18/25 contains MiraLAX with no specified diluent. COS with updated medication profile. Patient 4: The medication profile contains orders for Hydrocodone/acetaminophen 325mg 1 every 6 hours prn, Fentanyl 50 mcg every 72 hours and Dilaudid 1mg/ml hourly PRN on agency med profile and no evidence of meds on ALF profile Fentanyl 25 mcg 1 patch every 72 hours, Morphine Sulfate 20mg/ml dose 0.5 ml every hour prn, and Warfarin 5 mg on agency medication list with no evidence on Agency Med list. Updated POC 11/19/25 and IDG 12/11/25 COS Dc’s Dilaudid. COS with updated medication profile. Patient 5: The medication profile 12/15/25 contains orders for Metoprolol daily and Bumetanide twice daily. Wife reports during home visit “Bumex is once daily and he hasn’t taken the Lasix in a very long time.” There is no evidence of Metoprolol in home with medications. Wife reports patient takes Vitamin D3 and B12 daily and vitamins are present with home medications and not on medication profile. COS with updated medication profile. Patient 7: The medication profile contains orders for Doxycycline for 6 days ordered 9/3/25 remains active on medication profile with no end date. COS with updates to medication orders. Patient 9: The medication profile on 12/16/25 contains orders for Lorazepam and Melatonin and patient denies taking and medications not present in home. Patient reports taking Lisinopril and Cyclobenzaprine and meds found in home and not on medication profile. COS with updated medication profile. Patient 10: The medication profile on 12/3/25 contains an order for Cipro for 10 days with no end date and remain active on medication profile. COS with updated medication profile. Patient 12: The medication profile at SOC on 10/29/25 contains orders for Tylenol 650 mg TID, acetaminophen 325 2 tabs every 6 hours prn and Hydrocodone 5-325mg acetaminophen every 6 hours prn with no limit not to exceed in 24 hours. COS with updated medication profile. Patient 13: The medication profile 10/13/25 contains an order for Acetaminophen 500 mg 2 tabs every 4 hours prn with no limit not to exceed in 24 hours. COS with updated medication profile. Patient 14: The medication profile on 12/05/25 at recertification contains an order for Diclofenac gel apply prn to affected areas and does not specify where to apply and contains orders for acetaminophen 650 mg rectally every 6 hours prn, acetaminophen 500mg 2 tabs every 6 hours prn and Hydrocodone 5-325mg acetaminophen every 6 hours prn with no limit not to exceed in 24 hours. COS with updates to medication orders.

Upon patient record review, 3 of 23 (Patient # 21, 22, and 23) 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 21: There in no evidence of a bereavement component included in the initial comprehensive assessment at SOC. Patient 22: There in no evidence of a bereavement component included in the initial comprehensive assessment at SOC. Patient 23: There in no evidence of a bereavement component included in the initial comprehensive assessment at SOC.

Upon patient record review, 1 of 23 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: 12/4/25 SN visit RN documents pain score 10 and Dyspnea score 5 on 1-10 scale. MD notified and aide reports to RN patient’s refusal of all care due to pain. Oxycodone discontinued and Fentanyl patch ordered. No follow up until next visit 12/8/25 RN documents patient “did not understand use of patches and had not started Fentanyl. Continues with uncontrolled pain.” RN visits scheduled weekly. Upon home visit 12/17/2025, patient reports pain “9” on 1-10 scale and “ran out of pain medication 2-3 days ago.” RN confirms that patient’s PRN medication is expected to be delivered later today. During home visit, patient states "I haven't been without pain since 2006." Patient lives alone and has no caregiver. There was no evidence of follow up by the RN between each weekly visit. COS after home visit, MD updated and new order obtained to increase Fentanyl patch to 75 mcg every 72 hours and agency plans a supervisory visit with RN to assess effectiveness.

Upon patient record review, 2 of 23 (Patient # 3 and 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 3: The POC on 10/18/25 contains an order for Eliquis. There is not evidence of problems/goals/interventions to include risk of bleeding noted on the POC. COS with update to POC. Patient 8: The POC on 11/18/25 contains an order for Warfarin. There is not evidence of problems/goals/interventions to include risk of bleeding noted on the POC. COS with update to POC.

Upon patient record review, 11 of 23 (Patient # 1 ,2, 3, 4, 5, 6, 7, 8, 9, 10 and 18) 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 measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice and is used as part of the Hospice's QAPI program. Patient 1,2,3,4,5,6,7,8,9,10 and 18: There is no specific measurable times frames/target dates on goals in Problem/Intervention/Evaluation section of the record. COS with updates to POC to include specific measurable goals and timeframes.

Upon patient record review, 7 of 23 (Patient # 3, 4, 5, 9, 12, 13 and 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 3: The POC on 10/18/25 contains MiraLAX with no specified diluent. COS with update order and POC. Patient 4: The POC contains orders for Hydrocodone/acetaminophen 325mg 1 every 6 hours prn, Fentanyl 50 mcg every 72 hours and Dilaudid 1mg/ml hourly PRN on agency med profile and no evidence of meds on ALF profile Fentanyl 25 mcg 1 patch every 72 hours, Morphine Sulfate 20mg/ml dose 0.5 ml every hour prn, and Warfarin 5 mg on agency medication list with no evidence on Agency Med list. COS with updated orders and updated POC. Patient 5: The POC 12/15/25 contains orders for Metoprolol daily and Bumetanide twice daily. Wife reports during home visit “Bumex is once daily and he hasn’t taken the Lasix in a very long time.” There is no evidence of Metoprolol in home with medications. Wife reports patient takes Vitamin D3 and B12 daily and vitamins are present with home medications and not on medication profile. COS with updated orders and updated POC. Patient 9: The POC on 12/16/25 contains orders for Lorazepam and Melatonin and patient denies taking and medications not present in home. Patient reports taking Lisinopril and Cyclobenzaprine and meds found in home and not on medication profile. COS with updated orders and updated POC. Patient 12: The POC at SOC on 10/29/25 contains an order for Voltaren apply 2 times daily to both knees. Does not specify amount to apply and contains orders for Tylenol 650 mg TID, acetaminophen 325 2 tabs every 6 hours prn and Hydrocodone 5-325mg acetaminophen every 6 hours prn with no limit not to exceed in 24 hours. COS with updated orders and updated POC. Patient 13: The POC 10/13/25 contains an order for Acetaminophen 500 mg 2 tabs every 4 hours prn with no limit not to exceed in 24 hours. COS with updated orders and updated POC. Patient 14: The POC on 12/05/25 at recertification contains an order for Diclofenac gel apply prn to affected areas and does not specify where and amount to apply and contains orders for acetaminophen 650 mg rectally every 6 hours prn, acetaminophen 500mg 2 tabs every 6 hours prn and Hydrocodone 5-325mg acetaminophen every 6 hours prn with no limit not to exceed in 24 hours. COS with updated orders and updated POC.

Upon patient record review, 1 of 23 (Patient # 17) 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 17: The POC updated at recertification on 12/16/25 contains orders for Ipratropium/albuterol nebulization 4 times daily with no evidence of nebulizer equipment noted on POC. COS the patient currently refused nebulizer equipment and equipment/medication was discontinued from the POC during survey.

Upon patient record review, 3 of 23 (Patient #21, 22,23) 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 21: There is no evidence of the development of a bereavement plan of care. Patient 22: There is no evidence of the development of a bereavement plan of care. Patient 23: There is no evidence of the development of a bereavement plan of care.

Upon patient record review, 6 of 23 (Patient # 1, 2, 3, 4, 9, 13 and 18) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The Aide POC 10/14/25 includes task options for aide choice of bathing options for bed bath or shower every visit if shower is tolerated or bed bath if shower is not tolerated and assist to toilet as tolerated. There was no evidence documented that patient cognitively can make the decision. COS with updated POC. Patient 2: The Aide POC 08/13/2i includes task options for aide choice of bathing options for bed bath or shower every visit if shower is tolerated or bed bath if shower is not tolerated and assist to toilet as tolerated. There was no evidence documented that patient cognitively can make the decision. COS with updated POC. Patient 3: The Aide POC 10/18/25 includes tasks for nail care and change lines as needed and options for aide choice of bathing options for bed bath, partial sponge, shower every visit if shower is not tolerated. There was no evidence documented that patient cognitively can make the decision. COS with updated POC. Patient 4: The Aide POC 09/20/25 includes task options for aide choice of bathing options for bed bath or shower every visit if shower as tolerated or bed bath if shower is not tolerated and assist to toilet as tolerated. There was no evidence documented that patient cognitively can make the decision. COS with updated POC. Patient 9: The Aide POC 9/20/25 indicates choice of tasks including assist to BSC every visit as tolerated and assist to toilet every visit as tolerated. There was no evidence documented that patient cognitively can make the decision. COS with updated POC including all appropriate tasks. Patient 13:The Aide POC on 12/05/24 only includes only two tasks for aide to complete including standby assist and shower. There is no evidence of a complete list of aide tasks to be completed on the Aide POC. There is documentation of patient's poor cognition due to diagnosis of neoplasm of brain. COS with additional aide tasks added to updated POC. Patient 18: The Aide POC on 11/03/25 include task options for aide choice of bathing including bed bath or shower to be chosen by aide. There was no evidence documented that patient cognitively can make the decision. COS with updated POC.

Upon patient record review 2 of 23 (Patient # 1 and 2) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The Aide POC on 10/14/25 indicates Aide frequency 5 times weekly. The week of 12/1/25, there is evidence of only 4 aide visits completed. COS with updated frequency orders and updated POC. Patient 2: The Aide POC contains frequency 5 times weekly. The week of 11/24/25, there is evidence of only 4 aide visits completed. COS with updated orders and updated POC.

Upon client record review, 1 of 23 (Patient #2) 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 2: Specific ostomy care orders is not noted on the facility or hospice POC. COS with updated orders and POC.

Upon client record review, 1 of 23 (Patient # 2) 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 2: The updated POC on 11/11/25 contains instructions for ostomy care. There is no evidence of specific details on who should be providing ostomy care at facility. COS with updated orders and updated POC.