Every finding on record at Shepherd Living Hospice LLC

Upon patient record review, 2 of 14 (Patient #2, 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: The medication list recorded, "Acetaminophen 500mg 1 tablet by mouth every 6 hours as needed pain/fever." and "Acetaminophen 650mg rectal suppository every 4 hours as needed pain/fever." There was no evidence of any clarification on when one medication should be administered versus the other or of a maximum dose of Acetaminophen within a 24 hour period. Also, Dermacinrx 5% cream was present on the medication list with the instructions, "apply to affected area as needed." There was no evidence of clarification of where to apply the medication on the body or of how often a the dose stated, "per instructions" and the frequency recorded, "as needed." Further, there was found to be three pain medications listed on the medication list; Acetaminophen, Tramadol, and Morphine Sulfate. These were all "as needed" medications with no clarification present on any medication as to when to administer one drug versus the other related to pain intensity, severity, or numeric rating. Patient 5: The medication lists recorded, "Acetaminophen 300mg with Codeine 30mg 1 tab po q 6 hours prn pain" and "Hydrocodone 5mg-Acetaminophen 325mg 1 tab po q 6 hours PRN pain." No further documented evidence of clarification present on these medications as to when to administer one drug versus the other related to pain intensity, severity, or numeric rating.

Upon patient record review, 1 of 14 (Patient #5) 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 5: There is no evidence patient assessment update occurred as frequently as the condition of the patient requires, but no less frequently than every 15 days as there was no documented evidence of an RN visit completed from the last visit date of 10/24/25 through 11/12/25.

Upon patient record review, 1 of 14 (Patient #1) 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 1: The Recertification Plan of Care dated 11/04/25 recorded, "MSW 3 PRN for urgent psychosocial needs or interventions." There is no documented evidence of clarification of scope and frequency of psychosocial services necessary to meet the patient and family needs.

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: The plan of care recorded, "Acetaminophen 500mg 1 tablet by mouth every 6 hours as needed pain/fever." and "Acetaminophen 650mg rectal suppository every 4 hours as needed pain/fever." There was no evidence of any clarification on when one medication should be administered versus the other or of a maximum dose of Acetaminophen within a 24 hour period. Also, Dermacinrx 5% cream was present on the plan of care with the instructions, "apply to affected area as needed." There was no evidence of clarification of where to apply the medication on the body or of how often as the dose stated, "per instructions" and the frequency recorded, "as needed." Further, there was found to be three pain medications listed on the plan of care; Acetaminophen, Tramadol, and Morphine Sulfate. These were all "as needed" medications with no clarification present on any medication as to when to administer one drug versus the other related to pain intensity, severity, or numeric rating. Patient 5: The plan of care recorded, "Acetaminophen300mg with Codeine 30mg 1 tab po q 6 hours prn pain" and "Hydrocodone 5mg-Acetaminophen 325mg 1 tab po q 6 hours PRN pain." No further documented evidence of clarification present on these medications as to when to administer one drug versus the other related to pain intensity, severity, or numeric rating.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The plan of care effective 09/17/25 recorded a SN frequency of once weekly. There is no documented evidence of a SN visit completed or any missed visit documentation by either RN or LVN from the last visit date of 10/24/25 through 11/12/25.

Upon patient record review, 1 of 14 (Patient #5) 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 5: The recertification nursing assessment dated 09/22/25 indicated the patient is a high risk for falls with recent functional decline. The plan of care update with a date of 09/23/25 records problems, interventions, and goals related to fall precautions, safety measures and functional mobility. The aide instructions dated 06/20/25 did not provide any instruction to the aide regarding fall precautions. There is no documented evidence found of updated aide instructions to reflect the current needs of the patient.

Upon patient record review 1 of 14 (Patient #7) 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 7:The aide instructions dated 06/30/25 specified each required task to be completed at each visit. The aide visit dated 10/30/25 indicated shampoo and hair care tasks as, "not required this visit." The aide visit dated 11/03/25 indicated shampoo, hair care, and change linen tasks "not required this visit." The was no documented evidence found of collaboration with the case manager for these tasks to not be performed or of who, if anyone, refused these tasks for this patient with a terminal diagnosis of Senile Degeneration of the Brain.

Upon contract review, 2 of 4 (Medical Director and Alternate Medical Director contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Contracts 3 and 4 both recorded, "Hospice Medical Director Contract." The contracts did not specify any difference in roles and responsibilities pertaining to the Medical Director or Medical Director Designee role nor clarify who was to assume the "Director" versus "Designee" role. The Governing Body minutes, Organization chart, IDG documents, and EMR did distinguish clearly who these roles fell to within the organization.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment and reassessment that identify the patient's need for hospice care and services. For example: on review of RRHV#3 the documentation on the initial nursing comprehensive assessment noted the need for volunteer services, yet there was no documentation noted on the record that volunteer services were offered or further assessment of the need for volunteer services was addressed. Similar need for volunteer was noted in the records RRNHV#6, RRNHV#7, and RRNHV#9, yet no further assessment for volunteer services was documented. In review of RRNHV#9 there was documentation from the hospice aide that the patient was experiencing pain, and had open area in the skin and the findings were reported to the RN. There was no documentation noted that the nurse followed up and provided an assessment to identify the patients needs. These observations were reviewed with the Administrator and DON.

Observed in Record Review. In 11 of 14 patient records reviewed, the organization failed to ensure that update of the comprehensive assessment is based on changes that have taken place since the initial assessment and in include information about the patient's progress toward desired outcomes and reassessment of patient's response to care. For example: in review of clinical records where the patient had been on service over a period of time the plan of care lacked documentation of progress toward goals as the care plan goals and interventions remained the same IDG to IDG. During the IDG meeting the team discussed the updated comprehensive assessment, yet did not discuss the patient's progress toward goals and outcomes. This observation was reviewed with the Administrator and DON.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals. Throughout the records reviewed, goals were noted to lack being individualized, specific, measurable, and time bound. For example: in RRHV#2 a goal stated patient experiences spiritual comfort, and patient will remain free of falls as disease process allows. In RRHV#3 examples of goals were agitation/restlessness will be managed to patient/patient caregiver's comfort as disease process allows, patient will be maintained in safe environment, and patient/family effective coping abilities increased. In RRHV#4 examples were patient will function at maximum cognitive level and patient will be maintained in a safe environment. All goals lacked being time-bound with an ending date of the end of the benefit period. These observations were reviewed with the Administrator and DON.

Observed in Tracer Activities. the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions, to include a statement of the scope and frequency of the services necessary to meet the patient and family needs. For example: on review of the volunteer program the log of volunteer hours noted visits to patient homes, however on discussion with the volunteer coordinator there were no plans of care to direct the volunteers visits, nor were there physician orders for volunteer services to include an established frequency. These observations were reviewed with the Volunteer Coordinator, the Administrator, and the DON.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to ensure the plan of care included all services drugs and treatments needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#4 the medication profiled included Norco, Morphine, and Acetaminophen yet no specific instructions to guide the patient as to which medication to choose for the type or level of pain experienced. In RRNHV#1 the patient had Albuterol, Acetaminophen, Albuterol/Ipratropium, and Mucinex ordered for PRN use but no indication for use. In RRNHV#4 the patient had multiple laxatives ordered yet no instructions to guide the user when to use which medication. In RRNHV#8 the patient has Azithromycin ordered as directed without specific directions or indication as required. These observations were reviewed with the Administrator and DON. Observed in Record Review. In 5 of 14 patient records reviewed, for active patients, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the documentation noted that the patient was finishing doses of IV antibiotics per family, yet there were no physician orders for the medications or their administration, nor were the treatments reflected on the plan of care. Further, discussion with the primary caregiver for RRHV#1 the patient was diabetic and receiving insulin based on blood glucose monitoring by the PCG, yet there were no orders for blood glucose monitoring reflected on the plan of care. The patient also had a g-tube for medications and feeding and the nurse on home visit was observed providing site care, but the care was not reflected in the orders or care plans. Documentation in review of RRHV#2 noted a wound to the left lower extremity, and later to the coccyx yet there were no physicians orders for wound care nor was the care reflected on the plan of care. In review of RRHV#4 the documentation noted multiple falls and a UTI yet the issues were not reflected in the care plans. In RRNHV#1 and RRNHV#9 the documentation noted wounds with wound care provided, but no orders on the plan of care for wound care, nor were the wounds included in the care plans. In RRNHV#4 the record noted that patient was utilizing a Trilogy, with setting orders scanned in the record, but the treatment was not reflected on the plan of care. The patient also had a G-tube for nutrition, but no physicians orders for tube feedings. These observations were reviewed with the Administrator, and DON.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings. For example: on review of RRBR#1 the documentation on the day prior to the patient's death was experiencing pain, restlessness, and shortness of breath, but there was no documentation that the changes in status were reported to the RN case manager, and the IDG Team. This observation was reviewed with the Administrator and DON.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure that the registered nurse prepare a written patient care instructions for the hospice aide. For example: on review of RRHV#4 the aide assignment noted to provide skin care yet failed to specify the type of skin care to be provided or the area the skin care was to be provided. On home observation the patient was noted to have a open are to the buttocks however there were no instructions to the aide on how to approach the open area during the bathing process. Further, the patient was noted to be bed bound yet the task of assist with ambulation every visit was assigned and the family had requested that the patient's hair only be washed 3 times a week, yet it was still assigned for every visit. In review of RRHV#1 the patient have multiple wounds, a G-tube, and a PICC line, yet there were no specific instructions for how the aide was to handle the areas during bathing. In RRNHV#6 the aide was assigned both a shower and a bed bath. There was no indication that the shower was the primary bath. These observations were reviewed with the Administrator and DON.

Observed in Tracer Activities. the organization failed to maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. During review of the volunteer program and interview with the volunteer coordinator, it was noted that the organization failed to maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. The volunteer coordinator presented a log of volunteer hours that included a patient last name and a volunteer first name and a date and number of hours worked. The log did not include the type of service provided or time in or time out, and there was no documentation to support the entries in the log. On discussion with the volunteer coordinator, it was stated that the volunteers call the VC and to say that visit had been made, but no documentation was required of the volunteer to support the visit. Further, the organization was consistently well below 5% of total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with the volunteer coordinator, Administrator, and DON.

Observed in Patient Home. In 1 of 4 home visits conducted, The organization failed to ensure that hospice procedure was perform on a manner that is consistent with accepted standards of practice. For example: during the home observation for RRHV#1 the RN performed the procedure on discontinuing and pulling a PICC line. The organization noted they had adopted the Lippincott procedure manual which stated for after pulling a PICC line the procedure was apply petroleum based ointment and a sterile dressing for at least 24 hours to seal skin to the vein tract and reduce risk of air embolus. The RN was observed to apply pressure for 5 minutes and apply a pressure dressing to the site using gauze and Coban wrap. She instructed the PCG that the pressure dressing could be removed in an hour, which was not consistent with the organization accepted procedure. This observation was reviewed with the Administrator and DON.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the patient record reflected the patient's care, treatment, and services provided. For example: during the medication reconciliation observed during the home observation for RRHV#1 the medication profile noted in the record did not reflect the medications in use in the patient home. Hydrocodone, Lorazepam, Morphine, Ondansetron, and Lactulose were noted to be provided and present in the home but were not included on the medication profile in the record. Allopurinol was included on the med profile but per the caregiver it was not being given to the patient. Further, the PCG noted that the insulin and carvedilol were being administered as needed, yet they were ordered as scheduled, and were not noted to have parameters in the instructions. There were many medications that were noted to be given oral, yet the PCG explained in discussion that the all meds were crushed and given per peg tube. These observations were reviewed with the RN, DON, and Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, At the time of the patient’s discharge or transfer, the organization failed to inform other service providers who will provide care, treatment, or services with a discharge summary that included all of the required elements specifically noting the reason for discharge or transfer. On review of the closed record RRDC#1, a transfer, the d/c summary did not include a reason for discharge, nor was there any documentation that a copy of the d/c summary was provided to the accepting hospice. On review of RRDC#2 a discharge for extended prognosis the d/c summary did not include a reason for discharge nor was there indication that the summary was made available to the physician that was taking over care of the patient. These observations were reviewed with the Administrator and the DON.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure that for hospice care provided to a resident of a Skilled Nursing Facility, the hospice plan of care identify the care and services that are needed and identifies which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example: RRHV#2, RRNHV#1, and RRNHV#9 were residents of a skilled nursing facility and had wounds, yet there was no indication of coordination and/or collaboration of care to include delegation of duties between the facility and the hospice reflected in the plan of care for each patient. This observation was reviewed with the Administrator and DON.