Every finding on record at Priority Hospice Care Services, Inc

Upon patient record review, 2 of 15(Patient #1, #2) 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: Seroquel 25mg take 1/2 tab in home. Seroquel 12.5mg take 1 tab noted on POC med list. Patient #2: Mirtazapine 15mg take 1/2 tab on MAR in ALF. Mirtazapine 7.5mg tab take 1 noted POC med list. Vitamin B3 2000units was not listed on POC med list but noted to be on MAR in ALF.

Upon patient record review, 2 of 15 (Patient #3, #7) did not contain evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments; Patient #3: POC upon admission (7/7/25) did not reflect Seroquel 25mg tablet in the home it reflected Seroquel 12.5mg tablet. Patient #7: POC upon admission (4/12/25) did not reflect Mirtazapine 15mg tablet in the ALF, it reflected 7.5mg tablet. Vitamin B3 2000units was not included on the admission POC but was in the ALF for use.

Upon patient record review, 4 of 15 (Patient #4, #5, #6, #7) did not contain evidence that a revised plan of care included information from the patient's updated comprehensive assessment; Patient #4: SOC on 7/1/25. MSW comprehensive assessment on 7/2/25 and both SC and BC comprehensive assessments on 7/3/25; all three narratives reflected that they would be available if any needs arose and at every recertification period. However, each IDG updated POC, following SOC, still reflected "assessment to be completed within 5 days of admission" for all. Patient #5: SOC on 5/12/25. MSW comprehensive assessment on 5/13/25 and both SC and BC comprehensive assessments on 5/15/25; all three narratives reflected that they would be available if any needs arose and at every recertification period. However, each IDG updated POC, following SOC, still reflected "assessment to be completed within 5 days of admission" for all. Patient #6: SOC on 4/29/25. MSW comprehensive assessment on 4/30/25 and both SC and BC comprehensive assessments on 5/2/25; all three narratives reflected that they would be available if any needs arose and at every recertification period. However, each IDG updated POC, following SOC, still reflected "assessment to be completed within 5 days of admission" for all. Patient #7: SOC on 4/12/25. MSW comprehensive assessment on 4/13/25 and both SC and BC comprehensive assessments on 4/15/25; all three narratives reflected that they would be available if any needs arose and at every recertification period. However, each IDG updated POC, following SOC, still reflected "assessment to be completed within 5 days of admission" for all.

Upon patient record review 1 of 15 (Patient #7) did not contain evidence of documentation that a hospice aide provided services that were included in the plan of care: Patient #7: Aide plan of care indicated tub bath with each visit; during home visit patient was given bed bath. Aide plan of care indicated patients teeth be brushed at each visit; during home visit this was not completed. Aide plan of care indicated shaving with each visit; during home visit this was not completed. Aide plan of care indicated nails be cleaned at each visit; during home visit this was not completed.

Upon patient record review 1 of 15 (Patient #1) did not contain evidence 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 #1: the record lacked documentation of supervisory visits having been completed to date (10/07/25) for this patient after admission date of 09/10/25.

Upon patient client record review, 7 of 15 (Patient #1, #4, #6, #8, #9, #10, #14) did not contain evidence that all entries were appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice; Patient #1: RN progress note from 9/24/25 and HHA visit notes from 9/11/25 and 9/13/25 were still in "draft form" having not been completed and lacking signature/date. Patient #4: RN recertification note from 9/23/25 was not signed/dated. Patient #6: RN progress note from 9/30/25 and LVN progress notes from 05/04/25-06/22/25 were not signed/dated. Patient #8: Bereavement assessment from 03/24/25 was not signed/dated. Patient #9: Bereavement and Spiritual assessments from 11/30/23 were not signed/dated. Patient #10: Spiritual assessment from 10/22/23 was not signed/dated. Patient #14: RN progress notes from 8/10/25, 8/24/25 and 9/8/25 were still in "draft form" having not been completed and lacking signature/dates. LVN progress notes from 8/13/25, 8/20/25, 8/27/25 and 9/3/25 were not signed/dated.

Upon observation, there was evidence that the organization did not follow their policies and procedures to maintain the patient's clinical record in a confidential manner. There were (paper) patient records that were not available for review at start of survey.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, was made readily available on request by an appropriate authority.