Every finding on record at North American Hospice LLC

Upon patient record review 2 of 14 (Patient #3,#6) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3: There was no evidence the spiritual assessment was completed within 5 days. Patient #6:There was no evidence that a psychosocial assessment was completed within 5 days, admitted 10/2/25 and assessment completed 10/14/25.

Upon patient record review 4 of 14 (Patient #1,#8,#9,#14) 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. Patient #1: A Chaplain visited on 05-19-25, but there was no evidence of a completed spiritual assessment. Patient #8: A Chaplain visited on 09-09-25, but there was no evidence the spiritual assessment was completed. Patient #9: The Chaplain recorded a visit and documented speaking with son, but there is no evidence of a spiritual assessment being completed. Patient #14: The Chaplain made a visit within 5 days, but there is no evidence of a spiritual assessment being completed.

Upon patient record review, 4 of 14 (Patient #2,#8,#11,#14) 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 #2: There was no evidence of a route listed on the medication profile for Oxygen as ordered per the plan of care. In addition, Cephalexin was ordered on 08-29-25 for a skin rash, but remained on the medication profile until 10-21-25. Furthermore, Polyethylene glycol was listed on the medication profile without evidence of diluent instructions. Patient #8: Quetiapine and Metoprolol were listed on the medication profile without evidence of a quantity for administration per the order. Patient #11: MiraLAX was listed on the medication profile without evidence of a diluent. Patient #14: The SN visit note dated 04-16-25 indicated the patient was using O2 at 4LPM per NC, however, oxygen was not listed on the medication profile.

Upon patient record review, 2 of 14 (Patient #1,#8) 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 #1:There was no evidence a bereavement assessment was completed within 5 days of admission. Patient #8: There was no evidence that a bereavement assessment was completed within 5 days of admission.

Upon patient record review, 2 of 14 (Patient #1,#10) 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 #1: The patient had an order for and was receiving OT and PT services, but there was no evidence of PT and OT interventions or goals included on the plan of care. Patient #10: There were orders for wound care on Mon-Wed-Fri upon admission on 09-10-25. The orders for wound care were updated on 09-26-25 to include a dressing change every other day to an additional wound. However, there was no evidence the wound care was part of the written plan of care.

Upon patient record review, 5 of 14 (Patient #2, #3, #10, #11, #14) 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: There was no evidence of a stop date ordered for Cephalexin on 08-29-25. Additionally, there was no evidence of a diluent ordered for Polyethylene glycol. Patient #3: On 10-16-25 wound care orders were written for "Petroleum gauze, cut to fit wound bed" without evidence of a specific route/wound area. Additionally, "TAO 1 x week as needed" was ordered without evidence of an indication, location or as needed reason. Patient #10: There were orders for wound care on Mon-Wed-Fri upon admission on 09-10-25. The orders for wound care were updated on 09-26-25 to include a dressing change every other day to an additional wound. However, there was no evidence in order of who was to complete the wound care. Patient #11: MiraLAX was ordered without evidence of a diluent. Patient #14: The SN visit note dated 04-16-25 indicated the patient was using O2 at 4LPM per NC, however, there was no evidence of an order for oxygen.

Upon client record review, 3 of 14 (Patient #1, #7, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The patient had an order for and was receiving OT and PT visits however, there was no evidence of an order containing PT and OT frequencies. Patient #7: The plans of care dated 09-17-25 and 10-01-25 indicated the SN frequency was 2 x week, and the SW frequency was 1 x month. However, on the weeks beginning 10-5-25, 10-12-25 and 10-19-25, there was no evidence of a second SN visit or a missed visit note and during the month of September, there was no evidence of a SW visit or a missed visit note. Patient #9: The plans of care dated 09-03-25, 09-17-25 and 10-01-25 indicated SW visit frequency was 1 x month, however, there was no evidence of a SW visit in September.

Upon patient record review 5 of 14 (Patient #1,#2,#3,#5,#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 Patient #1: The aide care plan indicated "Shampoo" was assigned, but on aide notes dated 09-09-25, 09-12-25, and 09-23-25, a shampoo was not documented as completed and there was no evidence of the reason. Patient #2: The aide care plan indicated "Shampoo" and "shower" were assigned, but on aide notes dated 10-07-25, "shampoo" and "shower" were not documented as completed, and there was no evidence of a reason. On 10-14-25 the aide notes documented "shower"was not completed, but there was no evidence of a reason. Additionally, on10-08-25 there was no evidence any of he assigned tasks were documented as completed, though a visit by the aide was documented. Patient #3: The aide care plan indicated assigned tasks of "Shampoo" which was not completed per the aide visit notes dated 10-06,10-07, 10-09, and 10-10-25 and there was no evidence of a reason documented for noncompletion. Patient #5: The aide care plan indicated shower, foot care, skin care and nail care were assigned every visit. However, the aide notes dated 09-19-25, and 09-26-25 indicated the same tasks were not completed, but there was no evidence of a documented reason for not completing. Patient #9: The aide care plan indicated "Shampoo" was assigned every visit. However, per the aide notes dated 06-30-25, 07-30-25, 09-05-25 and 09-11-25, "shampoo" was not completed, but there was no evidence of a documented reason for not completing.

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. The total for 2024 was 3.27%. Agency currently has PIP in place.

Upon patient client record review, 1 of 14 (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 10-14-25, the RN documented a visit with a male patient receiving PT services at home, however, this patient was a female patient in an assisted living center with no PT services ordered.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The Election of Benefit did not have the Attending Physician Elected.

Upon patient record review, 1 of 14 (Patient #11) 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 #11: Medication profile included Miralax 17gm/scoop (1 powder Oral for Constipation) however there was no diluent on the medication profile.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: The facility was doing dressing changes however the RN never documents assessment of wound dressing or coordinates a time with the facility nurse to assess the wound together to ensure hospice management of patient's care.

Upon patient record review, 1 of 14 (Patient #11) 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 #11 order included Miralax 17gm/scoop (1 powder Oral for Constipation) however there was no diluent included in the order.

Upon patient record review, 1 of 14 (Patient #2) 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 no evidence that the plan of care has been updated with a skin integrity problem regarding the wound the assessment of the Sacrum and ankle wound.

Upon patient record review 8 of 14 (Patient #1,#3,#4,#6,#7,#8,#9,#10,#11) 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 #1: Aide ordered 5x week. One visit completed the week of 9/18/22, 3 visits completed the week of 10/9 and 4 visits completed the week of 10/16. Patient #3: Initially Aide ordered for 3x week. On 3/12/20 there is an order to discontinue the aide visits. Aide visits were restarted in April of 2021 however there was no evidence of an order to restart the aide services. Aide visits completed throughout August, September and October without an order. Patient #4: Aide ordered 3x a week. Two visits completed the week of 10/9. Patient #6: Aide ordered 5x a week. Four visits completed week of 9/18 and 10/9. Patient #7: Aide ordered 3x a week. Two visits completed the week of 7/24 and 10/10. Patient #8: Aide ordered 3x a week. Two visits completed the week of 10/9. Patient #9: Aide initially ordered for 5x a week. Only 4 visits completed the weeks of 9/18 and 9/25. In October visits were made at 3x a week. However there is no evidence of an order or plan of care update where the aide visit frequency changed to 3x a week. Patient #10: Aide ordered 5x a week. Four visits completed the week of 8/7 and 9/27, 3 visits completed the week of 10/9. Patient #11: Aide ordered 5x a week. Three visits completed the weeks of 8/7, 8/28, 9/18 and 9/25. Four visits completed the weeks of 9/4 and 9/11.

Upon personnel record review, 2 of 8 applicable (Personnel #8 and #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #8,#9: No evidence of competencies (Med Dir. and Alt Med Dir.).

Upon patient client record review, 1 of 14 records (Patient #5) 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 #5: The Election of Benefit did not have the Attending Physician Elected.