Every finding on record at My Comfort Care Hospice, Inc.

Upon patient record review, 2 of 14 (Patient #6,7) 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 • Drug therapy currently associated with laboratory monitoring #6-Med Profile dated 07/23/25 contains and order for Calmoseptine 1 tube topically to buttocks once daily for skin care. The amount dispensed reads as the application quantity which is not an appropriate application quantity. #7-Med Profile dated 04/15/25 contains and order for Diclofenac Sodium 1% 1 tube topically to back daily. The amount dispensed reads as the application quantity which is not an appropriate application quantity.

Upon patient record review, 2 of 14 (Patient #6,7) 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. #6-Plan of care dated 07/23/25 contains and order for Calmoseptine 1 tube topically to buttocks once daily for skin care. The amount dispensed reads as the application quantity which is not an appropriate application quantity. #7-Plan of care dated 04/15/25 contains and order for Diclofenac Sodium 1% 1 tube topically to back daily. The amount dispensed reads as the application quantity which is not an appropriate application quantity.

Upon patient record review 2 of 5 (Patient #2, #3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #2 and #3: There was no evidence that the comprehensive assessment contained a spiritual assessment.

Upon patient record review, 4 of 5 (Patient #1, #2, #4, #5) 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 #1: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 500mg 1 tab by mouth every 6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. [corrected on site] Patient #2: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 500mg 1 tab by mouth every 6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. [corrected on site] Patient #4: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 650mg 1 tab by mouth every 4-6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. Patient #5: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 650mg 1 tab by mouth every 4-6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco.

Upon patient record review, 4 of 5 (Patient #1, #2, #4, #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 medications and treatments. Patient #1: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 500mg 1 tab by mouth every 6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. [corrected on site] Patient #2: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 500mg 1 tab by mouth every 6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. [corrected on site] Patient #4: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 650mg 1 tab by mouth every 4-6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco. Patient #5: The medication profile listed Norco 5/325mg by mouth every 4 hours PRN for mod-severe pain and Tylenol 650mg 1 tab by mouth every 4-6 hours PRN mild pain-not to exceed 4gm/24 hours however, there was no evidence of maximum allowable for Norco.

Upon personnel record review, 1 of 1 applicable (Personnel 4) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #4: There was not evidence of signed job descriptions for alternate administrator or alternate DPCS.