Every finding on record at Morningside Hospice Inc.

Upon patient record review, 3 of 14 (Patient # 1,2,4) 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, caregiver at boarding care reports medications include Loperamide which is missing from agency medication profile and medication list contains three orders for Acetaminophen including 500mg 2 tabs every 6 hours PRN, 650mg one tabs every 6 hours orally and rectal suppositories 650 mg every 6 hours prn for fever with only one of the three orders specify to limit 24 hour dose to 3 grams. Corrected on site with medication reconciliation and new orders obtained. Patient 2: Upon home visit, agency medication profile contains orders for Lorazepam every 6 hours PRN and boarding home caregiver reports Lorazepam is given every 4 hours prn at group home and agency POC contains an order for Prochlorperazine two times daily PRN and boarding care medication list order is Compazine every 6 hours PRN for nausea. Corrected on site with medication reconciliation and new orders obtained Patient 4: Upon patient record review at SOC 8/2/25 includes medication orders for Acetaminophen 500mg 2 tabs 3 times daily scheduled for generalized pain and acetaminophen 650 mg rectal suppository 1 rectal suppository every 6 hrs PRN for temp >100 with no limit of 3 gm max daily dose. Corrected on site with order obtained with limit of 24 hours.

Upon patient record review, 4 of 14 (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: Upon home visit, caregiver reports medications include Loperamide which is missing from agency POC and updated POC on 7/25/25 contains three orders for Acetaminophen including 500mg 2 tabs every 6 hours PRN, 650mg one tabs every 6 hours orally and rectal suppositories 650 mg every 6 hours prn for fever with only one of the three orders specify to limit 24 hour dose to 3 grams. Patient 2: Upon home visit, updated POC contains orders for Lorazepam every 6 hours PRN and caregiver reports Lorazepam is given every 4 hours prn at facility and agency POC contains an order for Prochlorperazine two times daily PRN and boarding care medication list order is every 6 hours PRN for nausea. Patient 4: The initial POC on 8/2/25 contains two Acetaminophen orders including 500mg two tabs three times daily for generalized pain and acetaminophen 650 mg rectal suppository one Rectal suppository every 6 hrs PRN for temp >100 with no limit to not exceed 3 grams in 24 hrs. Patient 7: Initial POC 4/28/26 and updated POC 5/7/25 contain an order for indwelling foley change monthly as needed with no details for size, balloon instill solution, care of foley.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On updated POC 7/25/25 the frequency order for spiritual care provider is one visit/week and SC visits are being made one time monthly. Corrected on site with updated POC for correct visit frequency.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 3: Informed Consent for election of benefits start of care is dated as effective date 1/121/25.

Upon patient record review, 1 of 14 (Patient #9) 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 9: Initial Comprehensive Assessment 6/28/25 SN documents patient was evaluated and found to meet hospice criteria, admitted to Valley Oaks hospice and order is obtained at SOC to admit to routine level of care to Valley Oaks Hospice. Consents are signed correctly for Morningside Hospice.