Every finding on record at Lumicare Health Co 1

Upon patient record review, 3 of 19 (Patient #2,4,6) 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 2: On the medication profile there is an order for Latanoprost 0.005% eye drops and Timolol 0.5% eye drops, 1 drop, there are not instructions for one eye or both eyes. There is an order for Polyethylene Glycol 17g, there is no diluent. Corrected on site. Patient 4: On the medication profile there is an order MiraLAX 17g, there is no diluent. Corrected on site. Patient 6: There are medications on the facility medication profile that are not on the hospice medication profile/plan of care; Volteren External gel 1% 2 grams every eight hours. On the hospice medication profile there is an order for Morphine concentrate 10mg/ml 0.25ml every 4 hours as needed and is not on the facility medication profile. Corrected on site.

Upon patient record review, 3 of 19 (Patient #2,4,7) 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 2: On the patient plan of care there is an order for Latanoprost 0.005% eye drops and Timolol 0.5% eye drops, 1 drop, there are not instructions for one eye or both eyes. Corrected on site. Patient 4: On the recent plan of care there is an order for MiraLAX 17g, there is no diluent ordered. Corrected on site. Patient 7: There is evidence in the RN assessment that the patient has a foley catheter, there is not an order for the care of the foley.

Upon patient record review, 8 of 19 (Patient #3,4,7,8,10,11,12,14) 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 equipment and supply needs. Patient 3: On 10/7/25 the RN documented that there is oxygen in the home and the patient is on continuous oxygen. There is not an order for DME oxygen concentrator on the plan of care. Corrected on site. Patient 4: On 8/12/25 the RN documented that the Pt. has a walker/wheelchair, there is not an order for DME walker/wheelchair on the plan of care. Corrected on site. Patient 7: There is no DME listed on the recent plan of care, there is documentation in the patient record that the patient has a wheelchair. Corrected on site. Patient 8: There is no DME listed on the recent plan of care, however there is documentation in the SN assessment that the patient has a wheelchair. Corrected on site. Patient 10: On the plan of care there is an order for Albuterol for nebulization, there is not a nebulizer machine listed for DME on the plan of care. Corrected on site. Patient 11: In the RN assessment there is documentation that the patient has a wheelchair, there is not a DME order, walker on the plan of care. Corrected on site. Patient 12: On the RN comprehensive assessment the SN documents activity up as tolerated with walker, there is not a walker listed on for DME on the plan of care. Corrected on site. Patient 14: On the RN comprehensive assessment there is documentation that the patient is oxygen dependent, has a Hoyer lift and wheelchair, there is not a DME order with these items on the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) 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 7: There is evidence in the RN assessment that the patient has a foley catheter, there is not evidence on the plan of care of goals and interventions.

Upon patient record review, 2 of 19 (Patient #7,11) 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 • 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 7: On the aide plan of care there is an order to transfer client from bed to chair every visit as needed, the frequency cannot be as needed. Corrected on site. Patient 11: On the aide plan of care there is an order to shave every visit as needed, the frequency cannot be as needed. Corrected on site.

Upon patient client record review, 3 of 19 (Patient #1,2,13) 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 1: In the patient record the MSW documented, "Pt AXOX2", AXOX2 is not an approved abbreviation. Patient 2: On 9/22/25 the SN documented "VSS and O2SAT improved", VSS is not an approved abbreviation. On 9/22/25 the SN documented, "ENC Pt/fam to drink water", ENC and Fam are not approved abbreviations. Patient 13: In the patient record the chaplain documented, “SCC providing active compassionate listening”, SCC is not an approved abbreviation. Chaplain documented in the patient record, “Pt. BKGD is Muslim and pt’s son is able to contact mosque if needed”. SCC is not an approved abbreviation.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 16 (25%) clinical records reviewed, the hospice did not ensure the registered nurse followed the plan of care as ordered. Record 1: The patient’s date of election was 10/1/2022. A physician’s order effective 10/6/2022, ordered skilled nursing visits as, "3wk13". During the week of 10/9/2022-10/15/2022, there a nursing visit was documented as completed on 10/11/2022. There was no documented evidence of a second or third nursing visit completed that week, or documented reason for the missed visits. Record 2: The patient’s date of election was 4/28/2022. A physician’s order effective 5/2/2022 ordered skilled nursing visits as, "2wk12". During the week of 5/8/200-5/14/2022, there was no documented evidence of a nursing visit completed that week. or documented reason for the missed visits. Record 3: The patient’s date of election was 11/9/2022. A physician’s order effective 11/10/2022, ordered skilled nursing visits as, "2wk13". During the week of 11/13/2022-11/19/2022, a nursing visit was documented as completed on 11/15/2022. There was no documented evidence of a second nursing visit completed that week or documented reason for the missed visit. Record 9: The patient’s date of election was 4/8/2021. A physician’s order effective 1/6/2022, ordered skilled nursing visits as, "1wk7". During the week of 1/16/2022-1/22/2022, there was no documented evidence of a nursing visit completed or documented reason for the missed visit. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, the registered nurse did not complete visits as ordered on the plan of care. Record 1: The patient’s date of election was 10/1/2022. A physician’s order on 10/6/2022 effective 10/6/2022 ordered skilled nursing 3wk13. During the week 10/9/2022-10/15/2022, there was a nursing visit on 10/11/2022. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. Record 2: The patient’s date of election was 4/28/2022. A physician’s order on 5/2/2022 effective 5/2/2022 ordered skilled nursing 2wk12. During the week 5/8/200-5/14/2022, there was no documented evidence of a nursing visit or documented reason for the missed visits. Record 3: The patient’s date of election was 11/9/2022. A physician’s order on 11/10/2022 effective 11/10/2022 ordered skilled nursing 2wk13. During the week 11/13/2022-11/19/2022, there was a nursing visit on 11/15/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visits. Record 9: The patient’s date of election was 4/8/2021. A physician’s order on 1/4/2022 effective 1/6/2022 ordered skilled nurse 1wk7. During the week 1/16/2022-1/22/2022, there was no documented evidence of a nursing visit or documented reason for the missed visit. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, the registered nurse did not follow the plan of care as ordered.

It is required that each patient’s individualized written plan of care reflects patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records and interviews. In 3 of 16 (19%) clinical records reviewed, the hospice did not ensure the plans of care reflected patient and family goals and interventions based on problems identified in comprehensive assessments. Record 2: The patient’s date of election was 4/28/2022 with a primary diagnosis of chronic obstructive pulmonary disease. The plans of care dated from 4/28/2022 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 4/28/2022 stated, “repeated falls, last one two weeks ago that resulted in scapula and 4 rib fractures, a week ago patient had another fall, BLE +2 pit edema, increased dyspnea/fatigue with minimal exertion.” The plan of care did not include interventions or goals to specifically address the dyspnea, fall risk, or edema. Record 4: The patient’s date of election was 10/7/2022 with a primary diagnosis of systolic (congestive) heart failure. The plans of care dated from 10/7/2022 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 10/7/2022 stated, “3.5L continuous, pt experiences dyspnea with minimal exertion as evidenced by desaturation to high 80’s without oxygen.” The nursing assessment on 10/17/2022 stated, “3+ bilateral deep pitting edema, venous stasis ulcer, 1x1x0.1 cm left inner ankle.” The plan of care did not include interventions or goals to specifically address the dyspnea, edema or wound. Record 9: The patient’s date of election was 4/28/2021 with a primary diagnosis of sarcopenia. The plans of care dated from 4/28/2021 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 4/28/2021 stated, “sob, 4+ pitting bilateral edema, 3L oxygen.” The plan of care did not include interventions or goals to specifically address the edema or dyspnea. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, the plans of care did not include documented evidence of specific interventions or goals to address all problems identified in the comprehensive assessments. Record 2: The patient’s date of election was 4/28/2022 with a primary diagnosis of chronic obstructive pulmonary disease. The plans of care dated 4/28/2022 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 4/28/2022 revealed, “repeated falls, last one two weeks ago that resulted in scapula and 4 rib fractures, a week ago patient had another fall, BLE +2 pit edema, increased dyspnea/fatigue with minimal exertion.” The plan of care did not include interventions or goals to manage the dyspnea, fall risk or edema. Record 4: The patient’s date of election was 10/7/2022 with a primary diagnosis of systolic (congestive) heart failure. The plans of care dated 10/7/2022 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 10/7/2022 revealed, “pt describes pain as ‘stabbing’ lasting 30 seconds to a minute approximately. Pain rated 9/10 down to none. Pt takes oxycodone liquid 5mg for chest pain. 3.5L continuous, pt experiences dyspnea with minimal exertion as evidenced by desaturation to high 80’s without oxygen.” The nursing assessment on 10/17/2022 revealed “3+ bilateral deep pitting edema, venous stasis ulcer, 1x1x0.1 cm left inner ankle.” The plan of care did not include interventions or goals to manage the pain, dyspnea, edema or wound. Record 9: The patient’s date of election was 4/28/2021 with a primary diagnosis of sarcopenia. The plans of care dated 4/28/2021 to 11/29/2022 were reviewed. The comprehensive nursing assessment on 4/28/2021 revealed, “sob, 4+ pitting bilateral edema, 3L oxygen.” The plan of care did not include interventions or goals to manage the edema or dyspnea. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, the plans of care did not include documented evidence of interventions or goals based on problems identified in the comprehensive assessments for the records identified.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by a review of clinical records, document reviews, interviews and observations. During 2 of 4 (50%) home visit observations, the hospice did not ensure clinical staff demonstrated adherence to the agency's infection control policies and procedures for hand hygiene. Agency policy, “Hand Hygiene, Policy No. 7-009,” stated in part: “Hand decontamination using an alcohol-based hand rub should be performed: after contact with wound dressings, after contact with a patient’s intact skin (when taking a pulse, blood pressure), after removing gloves.” Home Visit 3 - During the home visit on 12/1/2022, the Registered Nurse (RN) (Staff 5) was observed performing the following activities, in sequence: washed her hands, took the patient’s pulse and blood pressure, donned gloves, opened wound supplies, donned gloves, removed the saturated wound dressing from the coccyx, removed gloves, donned gloves, completed wound care, opened dresser and removed briefs and placed them on the patient. The RN was not observed washing her hands after removing gloves, after contact with wound dressings, and after contact with the patient’s skin. Home Visit 4 - During the home visit on 12/5/2022, the Registered Nurse (RN) (Staff 6) washed her hands, took the patient’s pulse and blood pressure, and returned the used equipment to the nursing bag, which contained one compartment. The RN then pushed the patient in their wheelchair back to the community room. The RN was not observed washing her hands after contact with the patient’s skin. The Director of Clinical Services was interviewed on 12/5/2022 and agreed, the staff did not follow the infection control policy on hand hygiene. Agency policy, “Hand Hygiene, Policy No. 7-009,” stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: after contact with wound dressings, after contact with a patient’s intact skin (when taking a pulse, blood pressure), after removing gloves.” During observation of Home Visit #3 on 12/1/2022 at 11:45am, the Registered Nurse (RN) (Staff #5) washed her hands, took the patient’s pulse and blood pressure, donned gloves, opened wound supplies, donned gloves, removed saturated wound dressing on coccyx, removed gloves, donned gloves, completed wound care, opened dresser and removed briefs and placed on patient. The RN was not observed washing her hands after removing gloves, after contact with wound dressings or after contact with the patient’s skin. During observation of Home Visit #4 on 12/5/2022 at 9:00am, the Registered Nurse (RN) (Staff #6) washed her hands, took the patient’s pulse and blood pressure, returned used equipment to the nursing bag with one compartment. The RN pushed the patient in wheelchair back to community room. The RN was not observed washing her hands after contact with the patient’s skin. The Director of Clinical Services was interviewed on 12/5/2022 and agreed, the staff did not follow the infection control policy on hand hygiene.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 14 (21%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide followed the plan of care as assigned. Record 1: The patient’s date of election was 10/1/2022. The hospice aide documentation on the aide visit note dated 10/22/2022 stated that, “shower, shampoo” had been completed. The hospice aide plan of care dated 10/1/2022 did not include shower or shampoo as assigned tasks for the aide to complete. Record 4: The patient’s date of election was 10/7/2022. A physician’s order effective 10/13/2022 ordered hospice aide visits to be provided as, "1 x week for 8 weeks". During the week of 11/20/2022-11/26/2022, there was no documented evidence of a hospice aide visit completed or documented reason for the missed visit. Additionally, the hospice aide documentation on the visit note dated 12/1/2022 stated, “shower and shampoo no new concerns.” The hospice aide plan of care dated 10/7/2022 did not include shampoo as an assigned task for the aide to complete. Record 8: The patient’s date of election was 5/4/2022. A physician’s order effective 5/10/2022 ordered hospice aide visits to be provided as, "3 x weekly". During the week of 5/15/2022-5/21/2022, hospice aide visits were documented as completed on 5/17/2022 and 5/19/2022. There was no documented evidence of a third hospice aide visit completed that week or documented reason for the missed visit. During the week of 5/22/2022-5/28/2022, hospice aide visits were completed on 5/24/2022 and 5/26/2022. There was no documented evidence of a third hospice aide visit completed that week or documented reason for the missed visit. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Regional Director of Clinical Support & Education agreed, the hospice aide did not follow the plan of care as assigned. Record 1: The patient’s date of election was 10/1/2022. The hospice aide documentation on 10/22/2022 revealed, “shower, shampoo, catheter care.” The hospice aide plan of care dated 10/1/2022 did not include shower or shampoo as an assigned task. Record 4: The patient’s date of election was 10/7/2022. A physician’s order effective 10/13/2022 ordered a hospice aide 1 x week for 8 weeks. During the week 11/20/2022-11/26/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. Additionally, the hospice aide documentation 12/1/2022 revealed, “shower and shampoo no new concerns.” The hospice aide plan of care dated 10/7/2022 did not include shampoo as an assigned task. Record 8: The patient’s date of election was 5/4/2022. A physician’s order effective 5/10/2022 ordered a hospice aide 3 x weekly. During the week 5/15/2022-5/21/2022, there was a hospice aide visit on 5/17/2022 and 5/19/2022. There was no documented evidence of a third hospice aide visit or documented reason for the missed visit. During the week 5/22/2022-5/28/2022, there was a hospice aide visit on 5/24/2022 and 5/26/2022. There was no documented evidence of a third hospice aide visit or documented reason for the missed visit. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Regional Director of Clinical Support & Education agreed, the hospice aide did not follow the plan of care as ordered.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 3 (67%) clinical records reviewed with a discharge from hospice revealed the hospice did not ensure that the discharge summary was provided to the attending physician. Record 14: The patient’s date of election was 8/19/2021. The patient was discharged on 8/3/2022 when it was determined they no longer met hospice criteria. There was no documented evidence the discharge summary was sent to the attending physician. Record 15: The patient’s date of election was 8/31/2022. The patient’s daughter signed revocation paperwork on 9/14/2022 and the patient was discharged. There was no documented evidence the discharge summary was sent to the attending physician. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed there was no documented evidence the discharge summary was sent to the attending physician. Record 14: The patient’s date of election was 8/19/2021. The discharge was reviewed and revealed the patient was discharged-no longer meets hospice criteria on 8/3/2022. There was no documented evidence the discharge summary was sent to the attending. Record 15: The patient’s date of election was 8/31/2022. The discharge was reviewed and revealed the patient’s daughter signed revocation paperwork on 9/14/2022. There was no documented evidence the discharge summary was sent to the attending. The Regional Director of Clinical Support & Education was interviewed on 12/5/2022 and agreed, there was no documented evidence the discharge summary was sent to the attending.