Every finding on record at Lifechoice Hospice

Upon patient record review, 8 of 14 (Patient #1,2,4,5,6,7,8,10) 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 #1- 3/11/25 Miralax order did not indicate how to mix the powder for administration on the medication profile. Patient #2- 10/23/24 Orders for Lidocaine patch do not indicate where to apply the patch, Miralax order did not indicate how to mix the powder for administration on medication profile. Patient #4- 12/26/24 Acetaminophen 650mg RS Q4PRN, 2/28/25 Tylenol ES 500mg QD and Tylenol PM 500mg QHS, no evidence indicating "Not to Exceed 4000mg or max daily dose"on medication profile. This was corrected on site. Patient #5- Duplicate orders for Sertraline 50mg ordered 3/29/25 and 4/21/25 on medication profile. This was Corrected on Site. Patient #6- 7/5/24 Orders for Tylenol 500mg 2 tabs BID and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on medication profile. This was corrected on site. Patient #7- 1/22/25 Acetaminophen 650mg RS Q4PRN, Acetaminophen 325mg 1 tab QD and Acetaminophen 325mg 2 tab BID, no evidence indicating "Not to Exceed 4000mg or max daily dose"on medication profile. This was corrected on site. Patient #8- 3/11/25, Acetaminophen 500mg 2 tabs 3x/day and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on medication profile. This was corrected on site. Patient #10- 12/4/24 Acetaminophen 325mg 2 tab Q8 PRN and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on medication profile. This was corrected on site.

Upon patient record review, 8 of 14 (Patient #1,2,4,5,6,7,8,10) 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- 3/11/25 Miralax order did not indicate how to mix the powder for administration on the medication profile. Patient #2- 10/23/24 Orders for Lidocaine patch do not indicate where to apply the patch, Miralax order did not indicate how to mix the powder for administration on plan of care. Patient #4- 12/26/24 Acetaminophen 650mg RS Q4PRN, 2/28/25 Tylenol ES 500mg QD and Tylenol PM 500mg QHS, no evidence indicating "Not to Exceed 4000mg or max daily dose" on plan of care. This was corrected on site. Patient #5- Duplicate orders for Sertraline 50mg ordered 3/29/25 and 4/21/25 on medication profile. This was Corrected on Site. Patient #6- 7/5/24 Orders for Tylenol 500mg 2 tabs BID and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on plan of care. This was corrected on site. Patient #7- 1/22/25 Acetaminophen 650mg RS Q4PRN, Acetaminophen 325mg 1 tab QD and Acetaminophen 325mg 2 tab BID, no evidence indicating "Not to Exceed 4000mg or max daily dose"on plan of care. This was corrected on site. Patient #8- 3/11/25 Acetaminophen 500mg 2 tabs 3x/day and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on plan of care. This was corrected on site. Patient #10- 12/4/24 Acetaminophen 325mg 2 tab Q8 PRN and Acetaminophen 650mg RS Q4 PRN, no evidence indicating "Not to Exceed 4000mg or max daily dose"on plan of care. This was corrected on site.

Upon patient record review, 2 of 14 (Patient #2,9) 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- SN visits on 4/11/25 and 4/16 indicated patient was bed bound with use of hoyer lift and utilizes a broda chair for mobility, no evidence of DME orders on plan of care. This was corrected on site. Patient #9- 4/19/25 orders for oxygen administration, no evidence of DME on plan of care. This was corrected on site.

Upon patient record review, 1 of 14 (Patient #2) 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 #2- On 4/11 and 4/16, SN visit indicated patient was bed bound and used a broda chair for mobility, no evidence of problems, goals, intervention updated on the plan of care.

Upon patient record review 7 of 14 (Patient #1,2,3,6,7,9,10) 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 #1- On 3/16/25 the aide began giving the patient a bed bath at each visit, but the aide plan of care did not contain this type of bath to perform. Aide visits on 4/9, 4/10, 4/12, 4/14, 4/15 and 4/17 indicated to "assist with feeding", however no evidence that the task was completed. Aide visits 4/10 and 4/15 indicated on the care plan to perform "bed bath", however the task was not completed and the aide documented in the summary "patient given an peri wash". Patient #2-4/21/25 Aide checked task for bed bath "patient/caregiver refused", however documented in the narrative that a complete bed bath was given. Patient #3-4/14/25 Aide check task for feeding assistance as "no needs", however documented in the narrative that patient was fed. Patient #6-Aide visits 4/8, 4/11, 4/15 and 4/18/25 the aide checked the task of toileting as "patient/caregiver refused", however commented "Assisted patient to toilet and incontinence product changed". The aide checked "completed upon arrival" for change linen, however change linen was not an ordered task. Aide visit 4/11/25 had the tasks completed for Peri Care, Hair care and Skin care, however in the visit comments the aide stated "Family refused any care on the patient". Patient #7-Aide visits completed 4/11, 4/14, 4/15 and 4/18 indicated linen change was completed, however the task is only ordered 1x/week. Patient #9-Aide visits completed 4/1, 4/4, 4/9, 4/12, 4/16 and 4/18/25 the aide did not complete the ordered tasks for Oral Care, Back Rub, Tidy patient area and Feeding assistance, no evidence of why the task was not completed. Patient #10-Aide visits completed on 4/3, 4/4 and 4/6/25 the aide did not complete the ordered tasks for shampoo hair and provide companionship, no evidence of why the tasks were not completed.

Upon patient record review 1 of 14 (Patient #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 #9-Aide visits on 4/16 and 4/19/25 indicated the patient has pain during the visit, no evidence of pain reported to RN. 4/18/25 Aide visit indicated "patient with rash on vulva, spreading to butt", no evidence of reporting to the RN.

Upon patient record review 2 of 11 (Patient #10, 11) 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 10: SOC 8-11-2021, Spiritual care assessment was not completed until 9/13/2021. Patient 11: SOC 11/3/2021, Spiritual care assessment was not completed until 11/9/2021.

Upon patient record review 1 of 11 records (Patient #8) 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 8: SOC 2-10-2022, there was no evidence of a Spiritual assessment or Psychosocial assessment having been completed by any discipline.

Upon patient record review, 2 of 11 records (Patient #1, #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 Patient 1: Order 2/11/2022 included Cholestyramine 4GM powder for suspension, one packet 2x day for diarrhea PRN. There was no evidence of a diluent on medication profile. Corrected on site. Patient 11: Order dated 11/4/2021 included Lidoderm 5% topical patch, apply to intact skin for up to 12 hours, remove for 12 hours. There was no evidence of a site or reason.

Upon patient record review, 1 of 11 records (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: SOC 2-10-2022. There was no evidence of an initial bereavement assessment.

Upon patient record review, 1 of 11 (Patient #8) 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 8: SN visits ordered 1x every 2 weeks. A SN visit occurred 3/29/2022, a missed visit was noted for 4/13/2022, the next visit did not occur until 4/20/2022.

Upon patient record review, 2 of 11 records (Patient #1) 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: Order 2/11/2022 included Cholestyramine 4GM powder for suspension, one packet 2x day for diarrhea PRN. There was no evidence of a diluent. Corrected on site. Patient 11: Order dated 11/4/2021 included Lidoderm 5% topical patch, apply to intact skin for up to 12 hours, remove for 12 hours. There was no evidence of a site or reason.

Upon patient record review, 2 of 11 (Patient 6, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: A SN telehealth visit was made by RN 4/19/2022 due to pt. going out with daughter. There was no evidence in the POC of telehealth visits being approved by the physician. Patient 8: A SC telehealth assessment was made 2-11-2022. There was no evidence in the POC of telehealth visits being approved by the physician.

Upon patient record review, 7 of 7 applicable records (Patient # 1, #2, #3, #5, #9, #10, #11) 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 Patient 1: SOC SN documentation includes patient is high fall risk. There was no evidence of Fall risk on the HHA care plan. Corrected on site. Patient 2: SOC orders include O2, SOC SN documentation states patient is high risk for falls. There was no evidence of O2 precautions or Fall precautions on the HHA POC. Corrected on site. Patient 3: On SOC patient was on O2, and SOC SN documentation includes patient is high risk for falls. There was no evidence of O2 precautions or Fall precautions on the HHA POC. Corrected on site. Patient 5: On SOC patient was on O2, and SOC SN documentation includes patient is high risk for falls. There was no evidence of O2 precautions or Fall precautions on the HHA POC. Corrected on site. Patient 9: SOC SN documentation includes patient is high fall risk. There was no evidence of Fall risk on the HHA care plan. Patient 10: SOC SN documentation includes patient is high fall risk. There was no evidence of Fall risk on the HHA care plan. Patient 11: SOC SN documentation includes patient is high fall risk. There was no evidence of Fall risk on the HHA care plan.

Upon patient client record review, 1 of 11 records (Patient #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 7: There was a missed visit note for SW dated 4/17/2022 indicating "visit missed due to pt. passing and need for bereavement support". Patient remains on active census. Documentation clarified and corrected on site.

Upon personnel record review, 1 of 4 applicable records (Personnel #3) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 3: There was no evidence of a criminal background check.