Every finding on record at Mercy Hospice LLC.

Upon patient record review, 3 of 19 (Patient #3,4,6) 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 3: On the home visit there were medications in the patients home that are not on the medication profile. Trazadone 100mg at bedtime, carbidopa-levodopa 25-100mg 2 times daily, acetaminophen 650mg rectal suppository every 4-6 hours as needed. The patient has Metoprolol Tartrate 25mg ordered on the medication profile but the caregiver states the patient is taking Metoprolol succinate ER 25mg daily. Corrected on site. Patient 4: On the medication profile there is an order for acetaminophen 500mg 2 tablets 2 times daily, acetaminophen 650mg rectal suppository, every 6 hours as needed and Hydrocodone 5/325mg 1 tablet every 6 hours as needed. There is not a daily limit for acetaminophen written for these orders. Corrected on site. Patient 6: On the medication profile there is an order for acetaminophen 650mg rectal suppository every 4 hours as needed, acetaminophen ER 650mg 2 tablets 3 times daily as needed and Hydrocodone 5/325mg one tablet every 4 hours as needed daily. There is not a daily limit for the acetaminophen written for these orders. Corrected on site.

Upon patient record review, 3 of 19 (Patient #3,4,5) 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 3: On the current plan of care there is an order for Aspirin 81mg and Xarelto 20mg daily, there is not a risk of bleeding with goals and interventions on the plan of care. Corrected on site. Patient 4,5: On the current plan of care there is an order for Aspirin 81mg daily, there is not a risk of bleeding on the plan of care with goals and interventions on the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (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 medications and treatments. Patient 3: There is evidence in the patient record of a suprapubic catheter, there is not an order for the care and maintenance of the catheter. Corrected on site. Patient 3: On the home visit there were medications in the patients home that are not on the plan of care. Trazadone 100mg at bedtime, carbidopa-levodopa 25-100mg 2 times daily, acetaminophen 650mg rectal suppository every 4-6 hours as needed. The patient has Metoprolol Tartrate 25mg ordered but the caregiver states the patient is taking Metoprolol succinate ER 25mg daily. Corrected on site. Patient 4: On the plan of care there is an order for acetaminophen 500mg 2 tablets 2 times daily, acetaminophen 650mg rectal suppository, every 6 hours as needed and Hydrocodone 5/325mg 1 tablet every 6 hours as needed. There is not a daily limit for acetaminophen written for these orders. Corrected on site. Patient 6: On the RN initial assessment there is an assessment of a foley catheter. There is not an order for foley catheter care with goals and interventions. Corrected on site.

Upon patient record review, 1 of 19 (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 equipment and supply needs. Patient 1: Upon a home visit to the patient there was evidence the patient has a Hoyer lift, the Hoyer lift is not listed on the plan of care/DME supplies. Corrected on site.

Upon personnel record review, 1 of 14 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: On the competency assessment performed by the aide there is no evidence that there were techniques for shampoo in sink, tub and bed.

Upon patient record review 2 of 19 (Patient #11,13) 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 11: There is no evidence that an aide supervisory visit was made every 14 days between skilled nursing visits dated 12/11/25 and 1/6/25. The last supervisor visit made was on 12/11/25. Patient 13: There is no evidence that an aide supervisory visit was made every 14 days between the dates 12/5/25 - 12/19/25. There was a visit made on 12/5/25 and 12/23/25.

Upon patient client record review, 1 of 19 (Patient #5) 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 5: On the SN initial assessment there is documentation, "Pt. states she has to take rset periods, patient not able to tolerat treatment", this documentation is not clear and incomplete.

Upon patient record review, 1 of 13 (Patient #2) 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 2: The medication list indicates Miralax oral powder 17g po daily. There are no instructions for reconstitution of this powdered medication. (corrected onsite)

Upon patient record review, 1 of 13 (Patient #7) 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 7: The patient's family made an after hours call on 12.21.2022 to report the patient was lethargic and not feeling well; the family requested a PRN SN visit. The RN CM did make a PRN visit, during which she noted the patient to require treatment for UTI prevention. However, the RN did not document any contact or discussion with the MD, and did not provide any specific treatment orders, medication, or interventions to the family. When the RN made her next scheduled visit on 12.23.2022, she discovered the family had taken the patient to the emergency department on 12.21.2022 with a chief complaint of lethargy, where the patient was treated and released. During the survey, the administrator was able to determine the patient was given IVFs while at the ED, and had several labs checked that were essentially WNL. In both of these instances, the RN CM failed to follow up in the provision of care, following an assessment of need.

Upon patient record review, 1 of 13 (Patient #2) 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: A treatment order indicated hospice RN to insert indwelling catheter 18Fr/30cc balloon, irrigate with NS. Change catheter monthly or PRN. There is no specifier for the PRN catheter change instructions. (corrected onsite)

Upon patient record review 1 of 13 (Patient #7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 7: On the SN visit dated 12.14.2022, the SN determined that the patient may benefit from the services of a physical therapist; after discussion with the MD, orders were initiated for PT assessment. No further documentation was present in the patient's record regarding the PT visit until the SN visit on 01.09.2023, when the family inquired about the referral. The RN noted that she would check on the status of the referral, but there was no further documentation related to the referral or an upcoming visit in the patient's record. During the survey, the administrator was able to determine that the PT referral was faxed to the contracted agency the week of 12.14.2022; however, the therapy company said they never received the referral. It was confirmed that the therapy agency does not have the referral now, and a PT assessment has been scheduled for late January 2023.