Every finding on record at Passionate Hospice and Palliative Care, Inc.

Upon patient record review 10 of 14 (Patient #1, 2, 3, 5, 7, 9, 11, 12, 13, 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: There is no evidence that the comprehensive initial assessment identified the psychosocial or spiritual needs of the patient. Patient 2: There is no evidence that the comprehensive initial assessment identified the psychosocial needs of the patient. Patient 3: There is no evidence that the comprehensive initial assessment identified the spiritual needs of the patient. Patient 5: There is no evidence that the comprehensive initial assessment identified the psychosocial needs of the patient. Patient 7: There is no evidence that the comprehensive initial assessment identified the psychosocial needs of the patient. Patient 9: There is no evidence that the comprehensive initial assessment identified the psychosocial needs of the patient. Patient 11: There is no evidence that the comprehensive initial assessment identified the spiritual needs of the patient. Patient 12: There is no evidence that the comprehensive initial assessment identified the spiritual needs of the patient. Patient 13: There is no evidence that the comprehensive initial assessment identified the spiritual needs of the patient. Patient 14: There is no evidence that the comprehensive initial assessment identified the spiritual needs of the patient.

Upon patient record review, 5 of 14 (Patient #4, 5, 8, 9, 10) 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 Patient 4: The patient's oxygen does not appear on the medication list. Additionally, the narrative portion of the initial comprehensive assessment indicates that the patient utilizes Tylenol to relieve mild pain; however, Tylenol does not appear on the medication list. (corrected onsite) Patient 5: The patient's medication list indicates Miralax 17g powder daily for laxative; this is an incomplete entry as it does not indicate a route or instructions for reconstitution of this powdered medication. The list also contains Nystatin topical cream bid PRN for fungus; this is an incomplete entry as it does not indicate a location for this topical medication. Finally, the medication list includes oxygen 2L/min via nasal canula continuous or PRN for shortness of breath; this entry is ambiguous as oxygen cannot be indicated for both continuous and PRN use. The DPCS was able to confirm PRN use of oxygen. (corrected onsite) Patient 8: The patient's oxygen does not appear on the medication list. The list also contains hydrocortisone 1% topical cream daily PRN for rash; this is an incomplete entry as it does not indicate a location for this topical medication. (corrected onsite) Patient 9: The patient's oxygen does not appear on the medication list. (corrected onsite) Patient 10: The patient's medication list indicates oxygen 2L/min; this is an incomplete entry as it does not indicate a delivery method, frequency, or indication for use. (corrected onsite)

Upon patient record review, 8 of 14 (Patient #3, 4, 5, 6, 7, 8, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 3: Discipline orders for MSW services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) Patient 4: Discipline orders for MSW services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) Patient 5: Discipline orders for chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient.(corrected onsite) HA visits are ordered for 3 x weekly and PRN; the frequency of hospice aide visits cannot be ordered as PRN. (corrected onsite) Patient 6: Discipline orders for MSW and chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) Patient 7: Discipline orders for chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) HA visits are ordered for 3 x weekly and PRN; the frequency of hospice aide visits cannot be ordered as PRN. (corrected onsite) Patient 8: Discipline orders for chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) HA visits are ordered for 2 x weekly and PRN; the frequency of hospice aide visits cannot be ordered as PRN. (corrected onsite) Patient 9: Discipline orders for chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite) Patient 10: Discipline orders for MSW and chaplain services are ordered on an as needed basis only; should be detailed scope and frequency to meet individualized needs of the patient. (corrected onsite)

Upon patient record review, 2 of 14 (Patient #4, 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 4: The narrative portion of the initial comprehensive assessment indicates that the patient utilizes Tylenol to relieve mild pain; however, there is no indication of this over the counter medication in the patient's plan of care. (corrected onsite) Patient 9: The patient utilizes an oxygen concentrator; however, there is no indication of the oxygen treatment plan in the patient's plan of care. (corrected onsite)

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 equipment and supply needs. Patient 1: The patient requires the use of a cane, shower chair, and bedside commode for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 2: The patient requires the use of a cane and shower chair for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 3: The patient requires the use of a cane and shower chair for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 4: The patient requires the use of oxygen and a cane for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 5: The patient requires the use of oxygen for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 6: The patient requires the use of a cane, walker, wheelchair, and shower chair for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 7: The patient requires the use of a walker, wheelchair, and shower chair for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 8: The patient requires the use of oxygen and a cane for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 9: The patient requires the use of a cane and walker for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite) Patient 10: The patient requires the use of oxygen for management of the terminal illness; however, this equipment does not appear on the patient's plan of care. (corrected onsite)

Upon patient record review, 2 of 14 (Patient #5, 10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients 5, 10: At the time of recertification, there was no evidence that the hospice medical director reviewed the patient's record & clinical information and provided written documentation of anticipated life expectancy. Rather, an exact copy of the narrative portion from the nursing visit for recertification was copied and pasted into the physician narrative area.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Patient 8: The chaplain was hired on 08.14.2022; however, the criminal background check was not completed until 04.24.2024.