Every finding on record at Ms Hospice & Palliative Care, Inc.

Upon patient record review, 2 of 14 (Patient #5, 8) 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 5: The medication list records, "Polyethylene Glycol powder for solution 17g oral daily" but does not further instruct on the addition of a diluent for medication administration. The medication lists also records both "Acetaminophen 500mg 1 tab every 4-6 hours as needed" and "Norco 5mg-325mg every 6 hours as needed," however, there is no evidence of further directions clarifying a daily 4000mg maximum daily dose of Acetaminophen. Patient 8: The medication list records, "Miralax powder for solution 17g oral daily" but does not further instruct on the addition of a diluent for medication administration.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) 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 5: The plan of care records, "Polyethylene Glycol powder for solution 17g oral daily" but does not further instruct on the addition of a diluent for medication administration. The plan of care also records both "Acetaminophen 500mg 1 tab every 4-6 hours as needed" and "Norco 5mg-325mg every 6 hours as needed," however, there is no evidence of further directions clarifying a daily 4000mg maximum daily dose of Acetaminophen. Patient 8: The plan of care records, "Miralax powder for solution 17g oral daily" but does not further instruct on the addition of a diluent for medication administration. Patient 9: The plan of care records, "Flush PICC line weekly." There is no documented evidence of further clarification of this order to include instructions and solutions used for the maintenance of the PICC line.

Upon patient record review, 3 of 14 (Patient #2, 6, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The initial MSW assessment on 5/28/25 was completed via telephone. The plan of care does not indicate telephone visits are acceptable and there is no documented evidence of pt/cg requesting only a telephone visit or refusal of in person visit. Patient 6: Systolic blood pressure noted to be 169 at the 6/10/25 nursing visit. Per the plan of care, the physician should be notified of any systolic blood pressure greater than 160mmHg. There is no documented evidence the blood pressure was rechecked and decreased below reportable limits by the end of the visit or of physician notification. Patient 13: The initial SC assessment on 12/14/24 was completed via telephone. The plan of care does not indicate telephone visits are acceptable and there is no documented evidence of pt/cg requesting only a telephone visit or refusal of in person visit. The initial MSW assessment on 12/16/24 was completed via telephone. The plan of care does not indicate telephone visits are acceptable and there is no documented evidence of pt/cg requesting only a telephone visit or refusal of in person visit.

Upon patient record review 2 of 14 (Patient #3, 4) 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 3: The aide recorded, "Vitals were all within normal limits" during the 6/16/25 and 6/30/25 visits. The aide instructions do not indicate that vitals signs should be obtained by the hospice aide. Patient 4: The aide recorded, "Vitals were all within normal limits" during the 6/01/25 and 6/30/25 visits. The aide instructions do not indicate that vitals signs should be obtained by the hospice aide.

Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient 3: The aide documented, "discharge right eye" on the 5/15/25 visit. There is no documented evidence of this being reported to the RN case manager.

Upon patient record review 1 of 14 (Patient #5) 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 5: Hospice aide services initiated 5/25/25. There is no documented evidence of a supervisory visit being conducted between 5/25/25 and the last nursing visit on 6/29/25.

Upon personnel record review, 1 of 1 applicable (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.) ·(C) Shampoo, sink, tub, and bed Personnel Record #6: The competency checklist utilized by the agency does not differentiate the various types of shampoo; therefore, there is insufficient evidence that sink, tub and bed shampoos were validated.