Every finding on record at Mercy Hospice LLC

Upon patient record review, 2 of 19 (Patient #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 #4: There is evidence of an order on 4//21/26 for Fluconazole 200 mg daily for 5 days. The medication remains on the medication record. Patient #6: Upon observation the hospice medication record noted Depakote 500 mg at HS. The facility medication record noted Depakote 125 mg BID.

Upon patient record review, 1 of 19 (Patient #10) 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 #10: There is evidence in the medical record the patient was admitted on 1/4/26. The bereavement assessment was completed on 1/15/26.

Upon patient record review, 3 of 19 (Patient #5,10.11) 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 #5: There is evidence in the medical record the patient was admitted with Alzheimer's Disease and Dysphagia following cerebral infarction. There is not evidence of a Altered Neurological or Swallowing care plan. Patient #10: There is evidence on the initial nursing comprehensive assessment in the Spiritual section, "spiritual distress observed or reported". Spiritual distress was not added to the plan of care. Patient #11: There is evidence the patient was admitted with Cerebral Palsy and Seizures. Seizures is not on the plan of care.

Upon patient record review, 4 of 19 (Patient #4,5,6,12) 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 #4: There is evidence of an order on 4/21/26 for Fluconazole 200 mg daily for 5 days. The medication remains on the plan of care. Patient #5: There is evidence of a wound order on 5/11/26 "cleanse wound with soap and water, pat dry, apply barrier cream and apply foam dressing daily and as needed." The order does not indicate who will change the dressing. Patient #6: Upon observation the hospice medication order noted Depakote 500 mg at HS. The facility medication record noted Depakote 12 mg BID. Patient #12: There is evidence of a wound order on 1/15/26 "cleanse wound, pat dry, apply barrier cream and apply border dressing." The order does not indicate who will change the dressing or the frequency.

Upon patient record review, 5 of 19 (Patient #2,3,7,8,9) 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: There is evidence of an order for Zofran 4 mg q 6 hr PRN on 4/24/26. Goals and interventions for nausea and vomiting were not added to the plan of care. Patient #3: There is evidence of an order for MiraLAX 17 gm/dose mixed with 4-6 oz of fluid on 5/18/26. The plan of care was not updated with constipation goals and interventions. Patient #7: There is evidence in the certification of terminal illness on 4/8/26 stating the patient has decreased eating 50%. Goals and interventions for nutrition were not added to the plan of care. Patient #8: There is evidence in the medical record the patients primary diagnosis is Lewy body disease. The plan of care does not include goals and interventions for altered neurological. Patient #9: There is evidence the patient is admitted with Lung Cancer. The certification of terminal illness on 4/28/26 noted the patient is having dyspnea with exertion. There is no evidence of goals and interventions for altered respiratory on the plan of care.

Upon patient record review, 9 of 19 (Patient #1,2,4,7,8,9,10,11,14) 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 #1,2,4: There is evidence in the medical record the patient is taking ASA 81 mg daily. Bleeding precautions is not included on the aide plan of care. Patient #7,8,9,10,11,14: There is evidence in the medical record the patient has fall risk on the plan of care. Fall precautions is not on the aide plan of care.

Upon patient record review 1 of 19 (Patient #9) 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 #9: There is evidence the aide plan of care lists shampoo every visit. The aide visit frequency is 5x week. On 5/5/26, 5/6/26 and 5/7/26, the aide indicated "no" not required this visit on each note for shampoo.

Upon patient record review 2 of 19 (Patient #6,7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #6: There is evidence in the medical record of aide visit frequency 2x week. There was no supervision by the RN 3/27/26 thru 5/12/26. Patient #7: There is evidence in the medical record of aide visit frequency 2x week. There was no supervision by the RN 4/14/26 thru 5/13/26.

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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 2.85%

Upon patient record review, 2 of 19 (Patient #5, 7) 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 Patient 5: The medication list indicates an order on 05.02.2023 for diphenhydramine 12.5mg po tid PRN itching. On 05.30.2023, another order for Benadryl 25mg po q 6 hours PRN itching was added. The Clinical Supervisor verified with the RN Case Manager that this is a duplicate drug order, and that the earlier order for the same medication should have been discontinued when the increased dose was ordered. (corrected onsite) Patient 7: The medication list indicates an order on 04.24.2023 for Fentanyl 75mcg TD. On 05.15.2023, another order for both Fentanyl 25mcg and Fentanyl 50mcg was added. The Clinical Supervisor verified with the RN Case Manager that this is a duplicate drug order due to pharmacy supply chain issues, and that the earlier order for the same medication should have been discontinued when the substitute dosage was ordered. (corrected onsite)

Upon patient record review, 1 of 19 (Patient #11) 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 11: The comprehensive initial nursing assessment indicates that the patient has difficulty swallowing and requires thickened liquids for safety. The face to face examination prior to admission indicates the patient has a history of aspiration and confirms the order for thickened liquids. The patient resides in a SNF and requires assistance with ADLs, including feeding. However, no care plan was developed at the time of hospice admission, or subsequently, related to aspiration or airway safety. (corrected onsite)

Upon patient record review, 2 of 19 (Patient #1, 5) 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 1: The patient requires the use of a nebulizer for management of the terminal illness; however, this DME does not appear on the plan of care. (corrected onsite) Patient 5: The patient has a catheter and related supplies listed on the DME portion of the plan of care; however, the patient does not utilize this DME for management of the terminal illness. The Clinical Supervisor verified with the RN Case Manager that this DME was added to the plan of care in error. (corrected onsite)

Upon observation and patient record review, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 4: The patient experienced a fall at home on 05.13.2023; however, this event was not recorded on the adverse event log for data tracking and trending as a part of the hospice's QAPI program. (corrected onsite)