Every finding on record at Mercy Hospice LLC.

Upon patient record review, 1 of 1 (Patient # 13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 13: There is no evidence of imminence of death at SOC 09/30/24.

Upon patient record review, 5 of 14 (Patient # 1, 2, 3, 5, 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: Patient #1: Upon home visit review, the agency medication list contains an order for MiraLAX with no directions for diluent. COS Agency medication list was updated. Patient 2: Upon home visit, the agency's updated medication list 10/16/25 contains orders for Acetaminophen 325 mg 2 tabs every 6 hours prn and acetaminophen 650 mg rectal suppository every 4 hours PRN with no limit to not exceed in 24 hours and facility medication list does not contain comfort kit orders including oxygen, Lorazepam, and Ondansetron. COS Agency updated medication list to include limit to acetaminophen within 24 hours and removed comfort kit medications until needed. Patient 3: Upon home visit, the medication list on 10/16/25 contains multiple orders for acetaminophen 325mg 2 tabs every 4 hours, acetaminophen 325mg 2 tabs BID with no limit to not exceed 4gms in 24 hour and comfort kit medications are not listed on facility medication list. COS Agency updated medication list to include limit to acetaminophen within 24 hours and removed comfort kit meds until needed. Patient 5: The medication profile on 10/13/25 contains orders for MiraLAX with no diluent instructions, Latanoprost eye drops with no directions for which eye. Corrected on site with updated orders on medication profile. Patient 6: The SN comprehensive assessment at recertification, SN documents medication profile on 10/30/25 which contains orders for MiraLAX with no diluent instructions and multiple orders for acetaminophen including Tylenol 325mg 2 tabs every 4 hours PRN, Hydrocodone 5mg/325mg every 6 hours PRN and Rectal suppositories 650 mg every 4 hours PRN with no limit to not exceed in 24 hour period. Corrected on site with updated orders on medication profile.

Upon patient record review, 3 of 14 (Patient # 8,9,10) 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 8: The Initial POC 10/16/25 does not include orders for care of suprapubic indwelling catheter that is mentioned in SN documentation. The wound care orders on POC do not include frequency for wound care and location. COS POC updated. Patient 9: The updated POC 10/16/25 does not include orders for Indwelling foley and PEG tube care instructions or tube feeding pump. COS POC updated. There is no evidence of an order for tube feeding via PEG. SN documents in SN notes 10/31/25 tube feeding via PEG tube. Corrected on site with updated medication profile with ordered tube feeding. Patient 10: The updated POC on 10/05/25 does not include specific instructions regarding PEG tube care or nutritional support including tube feeding equipment. COS POC updated.

Upon patient record review, 2 of 14 (Patient # 9 and 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 equipment and supply needs. Patient 9: The POC does not include feeding tube infusion equipment. Corrected on site with updated POC. Patient 10: The POC does not include feeding tube infusion equipment. Corrected on site with updated POC.

Upon patient record review, 1 of 14 (Patient # 3) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 3: The aide POC on 09/19/25 contains directions for PRN tasks including shampoo, ear care, and nail as needed. Corrected on site with update to POC.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency 12 month cost savings is 2.99% of total patient care hours over 12 month period Oct 2024-Oct 2025 and was less than 5% for 2024.

Upon patient client record review, 1 of 14 (Patient # 8) 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 8 The initial POC on 10/16/25 contains a goal indicating "Fokey inserted on 12-19 and Woudn care will be managed without infection". COS with updated late entry.

Upon client record review, 5 of 14 (Patient # 1, 2, 4, 5, and 6) 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 1: The updated POC on 10/16/25 contains an order for MiraLax with no directions for diluent and Eliquis and Clopidogrel daily with no risk for bleeding identified on POC. COS POC updated. Patient 2: The updated POC on 10/16/25 contains orders for a325 mg 2 tabs every 6 hours PRN and acetaminophen 650 mg rectal suppository every 4 hours PRN with no limit to not exceed in 24 hours. COS POC updated. Patient 4: The initial POC on 9/16/25 contains orders for Clopidogrel with no evidence of risk for bleeding and does not contain orders for care of the PEG tube or PEG tube feedings. Corrected on site with order received for Isosource feedings and care of PEG tube and risk for bleeding added to POC. Patient 5: The updated POC on 10/13/25 contains orders for MiraLAX with no diluent instructions, Latanoprost eye drops with no directions for which eye and Eliquis order with no risk for bleeding noted on POC. Corrected on site with updated POC. Patient 6: At recertification, 10/30/25 the updated POC contains orders for MiraLax with no diluent instructions and multiple orders for acetaminophen including Tylenol 325mg 2 tabs every 4 hours PRN, Hydrocodone 5mg/325mg every 6 hours PRN and Rectal suppositories 650 mg every 4 hours PRN with no limit to not exceed in 24 hour period. COS POC updated.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel # 13: There is no evidence of background checks being obtained for volunteer who is under the age of 18 and has access to patient records for tuck in phone calls to patients/caregivers.

Upon patient record review, 2 of 11 (Patient #6, #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. Patient # 6-On 3/24/2022, the nurse documented the patient is on MiraLAX. MiraLAX is not listed on the medication profile. On 3/31/2022, the nurse documented the patient was on magnesium citrate prn. Magnesium citrate is not listed on the medication profile. Patient #10-The following medications are listed to be administered via oral route on medication profile: acetaminophen, alpha lypoic acid, atenolol, Ativan, Icar-C, MiraLAX, morphine sulfate, naproxen, Norco, KCL, Primidone, and Zoloft. On 10/3/2022 the nurse documented the facility nurse administers the listed medications via peg tube (oral route inaccurate). MiraLAX is listed on the medication profile as 17gm oral power as needed prn constipation. A diluent is not listed on the medication profile. Acetaminophen, morphine sulfate, and Norco are all listed on the medication profile as prn for pain; however, there no differentiation for the criteria for each to be administered.

Upon patient record review, 1 of 11 (Patient #2) 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. Patient #2-The bereavement risk assessment is not on record.

Upon patient record review, 2 of 11 (Patient #6, #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 specific orders for all medications and treatments. Patient # 6-On 3/24/2022, the nurse documented the patient is on MiraLAX. MiraLAX is not listed on the plan of care. On 3/31/2022, the nurse documented the patient was on magnesium citrate prn. Magnesium citrate is not listed on the plan of care. Patient #10-The following medications are listed to be administered via oral route on the 9/28/2022 plan of care: acetaminophen, alpha lypoic acid, atenolol, Ativan, Icar-C, MiraLAX, morphine sulfate, naproxen, Norco, KCL, Primidone, and Zoloft. On 10/3/2022 the nurse documented the facility nurse administers the listed medications via peg tube. MiraLAX is listed on the plan of care as 17gm oral power as needed prn constipation. A diluent is not listed on the plan of care. Acetaminophen, morphine sulfate, and Norco are all listed on the plan of care as prn for pain; however, there no differentiation for the criteria for each to be administered.

Upon patient record review, 1 of 11 (Patient #6) did not have evidence that all entries are clear. Patient #6-on 3/12/2022 the nurse documented the caregiver states they want a wider "pittycgair" (unclear/illegible).