Every finding on record at Main Street Hospice LLC

Upon patient client record review, 4 of 19 (Patient #2,6,7,13,) 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 #2 RN documentation on visit note 5/29/25 states "Dressing intact", 6/2/25 and 6/9/25 "wound care per care plan". LVN note dated 6/12/25 states, "wound care per care plan". Patient #6 LVN note dated 6/5/25 states, "Wound dressing change per care plan" Patient #7 POST form completed on admission, there is no year recorded in the "prepared on" date box, only month and day. Patient #13 RN visits dated 6/11/25 states,"wound care per care plan", and 6/16/25 states, "wound care performed by clinician, patient tolerated well"

Upon client record review, 1 of 19 (Patient #19) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #19 Revoked hospice benefit to seek aggressive treatment in the ER. No evidence of any information provided to the ER or physician.

Upon client record review, 2 of 19 (Patient #18,19) did not have evidence that the discharge summary includes all required information. Patient #18,19 Discharge summary did not include the following information: •A summary of the patient's stay, including treatments, symptoms and pain management •The patient's current plan of care •The patient's latest physician orders

Upon patient record review, 5 of 13 (Patient #1, #2, #4, #7, and #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: The medication profile included doxycycline 100mg two times per day x 5 days to begin on 4/15 -this medication remained active on profile. Guaifenesin ER 600mg tablets every 12 hours was on medication profile in duplicate. Acetaminophen 325mg tablet and Acetaminophen order 650mg rectal suppository. There was not evidence of a maximum allowable dose.{corrected on site} Patient #2 Medication profile contain Gentamicin with a start date of 4/29 for 10 days and it remained on the medication profile. Patient #4: The medication profile included miralax 17 gram/dose oral powder-give 17 grams every 24 hours as needed for constipation. There was not evidence of a diluent and the direction is unclear {corrected on site}. Patient #7: The medication profile included "hydrocodone 5mg-acetaminophen 325mg one tablet(s) every 6 hours as needed for" failed to include indicator for PRN use and included end date of 05/01/2022 but remained active on medication profile. {corrected on site} Patient #10: The medication profile included polyethylene glycol 350 17 gram/dose oral powder-give take 1-2 every day as needed for constipation. There was not evidence of a diluent and the direction is unclear {corrected on site}.

Upon patient record review, 4 of 13 records (Patient #1, #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 #1: The record indicated the oxygen order was to be 6lpm via nasal cannula while patient at rest, 10 lpm with exertion and 8-10lpm with activities when O2 sats go below 88%. For the dates of 04/01/2022-05/17-2022, nursing notes indicated oxygen ranged from 2lpm-5lpm (04/01-5lpm, 04/07-5lpm, 05/01-3lpm, and 05/17-2lpm). Acetaminophen 325mg tablet, take 2 tablets by mouth Q4 hours as needed for mild pain and headache dated 03/05/2022 existed with another acetaminophen order 650mg rectal suppository, insert 1 suppository rectally Q6 hours as needed for mild pain or fever. There was not evidence of a maximum allowable dose. Care plan indicated that patient used CPAP device, however, no orders were found with CPAP settings. Patient #2: The record indicated a CPAP on admission visit and care plan, however, record did not contain evidence of CPAP settings. Patient #4: The record revealed order dated 02/03/2022 for miralax 17 gram/dose oral powder-give 17 grams every 24 hours as needed for constipation. There was not evidence of a diluent and the direction is unclear {corrected on site}. Patient #7: The record did not show evidence of orders for paracentesis procedure or follow up for care of paracentesis site. Paracentesis performed on 03/08, 03/24, and 05/05. Medication order dated 03/03/2022 "hydrocodone 5mg-acetaminophen 325mg one tablet(s) every 6 hours as needed for" failed to include indicator for PRN use.

Upon patient record review, 3 of 13 records (Patient #3,#4, #6) 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: The record indicated a hospital bed in a SNF however, this was not listed on plan of care.{corrected on site} Patient #4 has a hospital bed, wheelchair, and over the bed table in a SNF however, this was not listed on plan of care.{corrected on site} Patient #6 has a hospital bed, over the bed table, and bed rails in a SNF however, this was not listed on plan of care. {corrected on site}

Upon client record review, 2 of 13 records (Patient #6 and #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: Plan of care indicated wound should be measured weekly and on both visits beginning week of 02/13/2022 (02/14/2022 and 02/17/2022) however there was no evidence of wound measurements. Patient #7 RN visit performed on 03/11/2022, nurse documented the patient port was accessed and flushed with NS and heparin however there is no evidence of physician orders to access port or for normal saline and heparin. "Right upper chest port accessed with 1 1/2" portacath needle, flushed with 10cc normal saline, good blood return for throw away blood. Blood specimen for BMP drawn, port flushed with 10cc normal saline and 5cc heparin. Port needle removed and site covered with bandaide."

Upon patient record review 4 of 12 applicable records (Patient #3, #4, #8, #12) 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 #3: The aide plan of care specified to shampoo hair weekly but documentation from the aide revealed this was performed more frequently 04/12 and 04/14, 4/25 and 04/29, 05/09 and 05/12. Patient #4: The aide plan of care specified to shampoo hair weekly but documentation from the aide revealed this was performed more frequently 05/03 and 05/06, 05/10, 05/12, and 05/13, 05/17 and 05/20. Patient #8: The aide plan of care specified to shampoo hair weekly, perform bed bath two times per week, and shower weekly but documentation from the aide revealed this was performed more frequently, shower performed on 05/11 and 05/13, shampoo performed on 05/11 and 05/13, 05/16 and 05/19. Patient #12: The aide plan of care specified to shampoo hair weekly, perform bed bath two times per week, and shower weekly but documentation from the aide revealed this was performed more frequently, shampoo performed on 01/19/2022 and 01/21/2022.

Upon personnel record review, 2 of 9 applicable records (Personnel #7,#8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. The competency checklist initially and annually was conducted by an RN.

Upon patient client record review, 2 of 13 (Patient #1 and 6) 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: The record indicated orders for wound care-cleanse with wound cleanser or normal saline, pat dry, apply medihoney, and cover with Allevyn dressing. On 05/03/2022, nurse documentation indicated wound care provided "per plan of care" but details were not included on nursing note{corrected on site}. Patient #6: The record indicated orders for wound care-Cleanse/irrigate with wound saline, apply medihoney, secure with Allevyn pad. On 02/28/2022, nurse documentation indicated wound care provided "per plan of care" but details were not included on nursing note.

Upon patient record review, 2 of 2 applicable records (Patient #3, #4) did not have evidence that the hospice provided the following information: • Names and contact information for hospice personnel involved in hospice care of each patient Patients #3, #4: Upon observed facility visits, there was not evidence of Names and contact information for hospice personnel involved in the hospice care. {corrected on site}