Every finding on record at Seacoast Angels Hospice, LLC

Upon patient record review, 1 of 14 (Patient #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 #5 - Medication profile did not contain oxygen but patient receiving O2 at 2L/min nasal cannula.

Upon patient record review, 1 of 14 (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 - Comprehensive assessment documented by RN on 10/31/25, then not again until 11/20/25.

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 - POC order stated to measure wound weekly but no measurements documented the week of 10/19/25, 11/09/25 or 11/23/25.

Upon patient record review, 2 of 14 (Patient #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 - Wound care to sacrum did not contain a frequency. Patient #5 - The plan of care did not contain oxygen but patient receiving O2 at 2L/min nasal cannula.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient #5 - Aide care plan assignment task for bathing contained both "full sponge bath 1 x week if patient refuses shower" and "shower 1 x week using shower chair" - did not document that patient was cognitively and functionally able to make decision.

Upon patient record review 5 of 14 (Patient #5,6,8,9,10) 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 #5 - Aide documented on 10/20/25 she provided both a full sponge bath and shower. Patient #6 - Aide documented she provided both a bed bath and shower, provided nail care and changed linen twice a week but ordered only 1 time a week on 11/10/25, 11/12/25, 12/01/25 and 12/03/25. Patient #8 - Aide documented she weighed patient every visit the month of November (twice a week) but only ordered 1 x month. Patient #9 - Aide documented on 12/10/25 she provided both a full sponge bath and shower. Patient #10 - Aide documented nail care three times a week, week of 10/20/25 and 11/09/25 but ordered 1 x week. Aide visit frequency three times a week but only provided two visits the week of 11/23/25.

Upon patient record review 1 of 14 (Patient #10) did not have evidence documentation 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 #10 - Aide supervisory visit documented on 10/31/25, then not again until 11/20/25.

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 annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount 4.08% for the FY 2024.

Upon patient record review 1 of 12 (Patient #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 #6 - SOC 10/26/2022 - SC assessment not completed until 11/01/2022.

Upon patient record review, 1 of 12 (Patient #10) 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 #10 - SOC 08/10/2022 - Initial bereavement completed 08/23/2022.

Upon patient record review, 1 of 12 (Patient #6) 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 #6 - POC 10/26/2022 did not contain foley catheter size.

Upon client record review, 4 of 12 (Patient #1, 3, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - POC 10/31/2022 MSW visit frequency 1 wk 13, No visit completed week 2. SN visit on 11/05/2022 documented warm heat applied to back for 20 minutes for back pain - no order for warm heat application. Patient #3 - POC 10/13/2022 SN 1wk1, 2wk1, 1wk1, 2wk 6 - wk 7 and 8 only 1 visit completed. Patient #5 - POC 11/02/2022 SN visit frequency 2 wk 10, 1 visit completed week 4. SC visit frequency 1 wk1, 1 every wk 4, 1 every wk5 - no visit made week 1. Patient #6 - POC 10/26/2022 MSW visit frequency 1 wk 9- no visit completed week 3.

Upon patient record review 4 of 12 (Patient #1, 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1 - POC 10/31/2022 aide frequency 5wk13 - week 4 only 4 visits completed. Patient #3 - POC 10/13/2022 aide frequency 2wk1, 5 wk5, 4wk1, 5wk2 - week 3, 4, 8 only 4 visits completed and week 7 only 3 visits completed. Patient #5 - POC 11/02/2022 aide frequency 1wk13 - no evidence of a visit week 2. Patient #9 - POC 09/01/2022 aide frequency 4wk1, 5wk 11 - week 1 only 3 visits completed, wk3 only 4 visits completed.

Upon patient client record review, 1 of 12 (Patient #5) did not have evidence that each patient record contains Advance Directives. Patient #5 - Patient record did not include Advance Directives.