Every finding on record at Partners in Care Hospice, LLC

Upon patient record review, 3 of 14 (Patient #1,2,4) 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: There is evidence of an order for Plavix 75 mg. Bleeding precautions is not on the initial plan of care. Patient #2: There is evidence ASA 81 mg. Bleeding precautions is not on the initial plan of care. Patient #4: There is evidence of an order for ASA 81 mg. Bleeding precautions is not on the initial plan of care.

Upon patient record review, 3 of 14 (Patient #,5,7,9) 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: There is evidence in the medical record of a Nurses note on 1/27/26 indicating "right hip dressing in place and heel protectors" There is no order for either. Patient #7: There is evidence of an order on 2/5/25 Left lateral malleolus, cleanse wound with NS, pat dry, cover with Mepitel and foam dressing 2xweek. There is no indication who will change the dressing. Patient #9: There is evidence of an order on 2/3/25 two skin tears, cleanse with NS, pat dry, cover with Opti foam 2xweek. There is no indication who will change the wound.

Upon client record review, 2 of 14 (Patient #6,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: There is evidence in the medical record of an order for Volunteer 1Xwk. In January the patient had 2 volunteer visits on 1/9 and 1/23/26. Two visits were missed. Patient #8: There is evidence in the medical record of an order for Volunteer 1Xwk. In January the patient had 2 volunteer visits on 1/2 and 1/16/26. Two visits were missed.

Upon patient record review 1 of 14 (Patient #1) 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 #1: There is evidence of an IDG communication note on 12/31/25 noting the IDG disciplines collaborated and identified the need for a volunteer. The Volunteer coordinator did not follow up with an assessment or order.

Upon observation during home visits 1 of 3, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: RN placed equipment on the floor during patient care.

Upon patient record review, 4 of 14 (Patient #1,2,4,6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There is evidence in the medical record12/19/25 of an order for Plavix 25 mg. Aide plan of care does not have bleeding precautions. Patient #2: There is evidence in the medical record 12/1/25 of an order 11/25/25 ASA 81 mg." There is not bleeding precautions on the aide plan of care. Patient #4: There is evidence in the medical record 12/3/25 of an order for ASA 81mg. Aide plan of care does not have bleeding precautions. Patient #6: There is evidence of a nurses note on 11/16/25 for "feeding assistance". The nurses notes indicate 11/15/25 the patient is 1:1 feed with pocketing food and aspiration precautions. Aspiration precautions are not on the aide plan of care. Additionally the 11/15/25 nurses note states the patient has history of seizures. Seizure precautions is not on the aide plan of care.

Upon patient record review 1 of 11 (Patient #8) 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 8: There was no evidence of a Spiritual care assessment in the comprehensive assessment.

Upon patient record review, 5 of 11 (Patient #2, #3, #4, #5, #9) 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: Medication profile included Nystatin 100,000u topical cream apply 2x day to affected site. There was no evidence of an area to apply the cream. Corrected on site. Patient 3: Medication profile included Hydrocortisone 1% topical cream small amount topically 2x day for rash. There was no evidence of an area to apply cream. An order dated 12/8/2022 included sacral wound cleanse with wound wash, pat dry, apply thin layer of medi-honey on wound then cover with bordered gauze. There was no evidence of frequency. These were on the medication profile. Corrected on site. Patient 4: Medication profile included Triamcinolone 0.1% topical ointment and Dimethisone 5% topical cream thin layer to affected areas as needed. There was no evidence of an indication/area to be be treated. Corrected on site. Patient 5: Medication profile included Lomotil 2.5mg-0.025mg tab 1 tab after diarrhea. There was no evidence of a route or frequency limit. Corrected on site. Patient 9: Medication profile included 1) Questran light 4 GM oral powder- admin 1 scoop by mouth at 8am and 5pm as needed. There was no evidence of a diluent to be used or an indication for the medication. 2) Citrucel sugar free oral powder admin 2 TBS 1 oz.oral as needed at 8am and 5pm. There was no evidence of a diluent to be used or and indication for the medication.

Upon patient record review, 1 of 11 (Patient # 10) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 10: Visit frequency of SN dated 11/7/2022 1 x week. There were no SN visits week of 11/6/22, 11/13/22, 11/20/22. The last nursing visit was documented as 11/3/2022, the next RN visit documented on 11/29/2022. There were missed visit notifications, no evidence of a compressive assessment for 26 days.

Upon patient record review, 5 of 11 (Patient #2, #3, #4, #5, #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 2: The POC on SOC included Nystatin 100,000u topical cream apply 2x day to affected site. There was no evidence of an area to apply the cream. Corrected on site. Patient 3: The POC from date 9/20/2022 included Hydrocortisone 1% topical cream small amount topically 2x day for rash. There was no evidence of an area to apply cream. The POC dated 12/20/2022 included sacral wound cleanse with wound wash, pat dry, apply thin layer of medi-honey on wound then cover with bordered gauze. There was no evidence of frequency or who would perform treatment. Corrected on site. Patient 4: The POC dated 12/1/2022 included Triamcinolone 0.1% topical ointment and Dimethisone 5% topical cream thin layer to affected areas as needed. There was no evidence of an indication/area to be be treated. Corrected on site. Patient 5: The POC dated 11/28/2022 included Lomotil 2.5mg-0.025mg tab 1 tab after diarrhea. There was no evidence of a route or frequency limit. Corrected on site. Patient 9: The POC dated 10/13/2022 included 1) Questran light 4 GM oral powder- admin 1 scoop by mouth at 8am and 5pm as needed. There was no evidence of a diluent to be used or an indication for the medication. 2) Citrucel sugar free oral powder admin 2 TBS 1 oz. oral as needed at 8am and 5pm. There was no evidence of a diluent to be used or and indication for the medication.

Upon client record review, 2 of 11 (Patient #10 and 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: MSW visits ordered 10/14/2022 for 2x month, no evidence of a visit or missed visit for month of November. Patient 11: SN visit frequency ordered on POC 9/1/2022 5x week with 5 PRN. Weeks of 9/4/22, 9/11/22, 9/18/22- 2 SN visits were made with no evidence of missed visits documented.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #4, #5, #7, #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1, 3, 4, 5: Per SOC SN assessment and POC patient is high fall risk. There was no evidence of fall risk precautions on the HHA assignment. Corrected on site. Patient 2, 7, 11: Per SOC SN assessment and POC patient is high fall risk. The patient is currently on O2. There was no evidence of fall risk precautions or Oxygen precautions on the HHA assignment. Corrected on site.

Upon patient record review 2 of 11 (Patient #6 and 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 6: Aide visits completed on 11/11/22 and 11/23/22, no evidence of an order for these visits. Patient 11: HHA visit frequency ordered 9/1/2022 POC included HHA 3X week and 5 PRN. For weeks of 9/4/2022 and 9/11/2022 there were 2 visits, week of 9/18/2022 1 visit, with no evidence of missed visits documented.

Upon patient client record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) 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 Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 There was no evidence of a signed notice of the patient rights. Patient 8: EOB signed by family, not signed by agency staff.

Upon patient client record review, 1 of 11 (Patient #9) did not evidence that each patient record contains physician orders. Patient 9: There was no evidence of a discharge order.

Upon patient client record review, 1 of 11 (Patient #11) 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 11: There was an order dated 8/1/2022 for SLP 4 visits PRN. This was an error. No evidence of appropriate authenticated entry.

Upon client record review, 2 of 11 (Patient #9, #10) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 9 and 10: There was no evidence of a discharge summary sent to the attending physician.

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 1: On SN SOC assessment discussed safe use and disposal of controlled substances was marked NA. Policy provided marked yes. There was no evidence of discussion.