Every finding on record at Rolling Meadows Hospice, LLC

Upon patient record review, 2 of 19 (Patient #9 and 12) 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 9: The medication list recorded, "MiraLax 17 powder (17gram/scoop) 1 times a day as needed for constipation." There is no further evidence of instructions to add a diluent to the medication. Also, Magic Mouthwash is recorded with the indication as "other symptoms" with no further documented evidence of the medication indication. Patient 12: The medication list recorded, "Acetaminophen 650mg suppository every 4 hours as needed pain/fever" as well as, "Hydrocodone-acetaminophen 5-325 every 4 hours as needed for pain." There is no further documented evidence of a maximum dose of Acetaminophen within a 24 hour period.

Upon patient record review, 3 of 19 (Patient #9, 12, 13) 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 9: The plan of care recorded, "MiraLax 17 powder (17gram/scoop) 1 times a day as needed for constipation." There is no further evidence of instructions to add a diluent to the medication. Also, Magic Mouthwash is recorded with the indication as "other symptoms" with no further documented evidence of the medication indication. Patient 12: The plan of care recorded, "Acetaminophen 650mg suppository every 4 hours as needed pain/fever" as well as, "Hydrocodone-acetaminophen 5-325 every 4 hours as needed for pain." There is no further documented evidence of a maximum dose of Acetaminophen within a 24 hour period. Patient 13:Wound care order recorded on the plan of care as follows, "wound care to right inner buttocks as follows: Clean lesion to right inner buttocks with normal saline. Pat dry with gauze. Cover with dry dressing PRN daily or if dressing or becomes soiled or dislodged, until lesion resolves/closes. SN to perform wound care weekly, CG to provide wound care all other days." There is no further clarification if the wound care should be performed daily AND PRN or if the wound care should be performed PRN each day only if soiled or displaced. This could lead to the dressing remaining in place every day between the "SN to change weekly" which would then require an order for once weekly and PRN.

Upon patient client record review, 3 of 19 (Patient #4, 9, and 12) 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 4, 9, and 12:Plan of care contains social work interventions as follows:"Establish a trusting relationship by visiting: 1-2 times a month and PRN, Establish a trusting relationship by visiting: once a week and PRN, Establish a trusting relationship by visiting: once every 2 weeks and PRN, Establish a trusting relationship by visiting: once every 3 weeks and PRN" This is inconsistent with the scope and frequency previously defined and is unclear in determining the patients true need.

Upon client record review, 1 of 19 (Patient #15) 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 15: There was no documented evidence found in the medical record that a copy of the discharge summary was supplied to the attending physician at the time the patient revoked hospice services.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient 6: The medical record contained a PRN visit on 6/27/25 conducted by the Spiritual Care Advisor. The note recorded, "The conversation focused on how she doesn't wish to live in the facility due to only being bathed once a week, she has no privacy, and she continues to experience pain even after taking her medication." There is no documented evidence of coordination of care by the Spiritual Care Provider to other members of the IDG or consultation/coordination of care with facility staff.

Upon patient record review 1 of 13 (Patient #7) 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 #7: Patient admitted 1/20/22- SW performed psychosocial assessment on 2/6/22.

Upon patient record review, 2 of 13 (Patients #2 and 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 #2: Duplicative oxygen on Medication profile. 7/12/21 O2 2-4LPM/NV PRN SOB AND 8/1/22 O2 2-5 LPM/continuous. First Oxygen order not deleted from Medication profile when new order entered. Patient #5: Duplicative oxygen orders on Medication profile. 2/5/22 O2 2-4LPM/NV PRN SOB AND 8/1/22 O2 2-5 LPM PRN SOB/. First Oxygen order not deleted from Medication profile when new order entered.

Upon patient record review, 1 of 13 (Patient #4) 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 #4: Bereavement risk assessment not performed at all for patient admitted 10/12/20.

Upon patient record review, 2 of 13 (Patients #2, 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 #2: Duplicative oxygen orders on POC, 7/12/21 O2 2-4LPM/NV PRN SOB and 8/1/22 O2 2-5 LPM/continuous. First Oxygen order not inactivated from POC when new order entered. Patient #5: Duplicative oxygen orders on POC, 2/5/22 O2 2-4LPM/NV PRN SOB and 8/1/22 O2 2-5 LPM PRN SOB. First Oxygen order not inactivated from POC when new order entered.

Upon client record review, 4 of 13 (Patients #2, 3, 8, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Chaplain ordered 1x mo and 1 prn. No evidence of visit in July or missed visit or order. Patient #3: Chaplain ordered 1x mo and 1 prn on POC dated 5/2/21. No evidence of visit in June, no missed visit or corrections orders Patient #8: SW ordered 1x mo and 1 prn on poc dated 2/21/22. No visit until 3/11/22. No missed visit or order or evidence of other attempts to see patient. Patient #13: SN wound care ordered as follows on 12/15/21 to top of head: Cleanse with normal saline, pat dry, apply collagen. SNV on 2/23/22 documentation performed: cleanse with normal saline, pat dry and applied santyl.