Every finding on record at Solace Hospice Care, LLC

Upon patient record review 2 of 14 (Patient #3, 8) 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 #3:The comprehensive assessment dated 01/25/26 indicated the patient had pain, but the comprehensive pain assessment was incomplete as evidenced by no description/character of pain, no duration and no side effects documented. However, the HOPE documentation indicated it was completed. Patient #8: The comprehensive assessment by the SN dated 07/18/25 indicated the patient had a chronic wound to the L foot. However, the wound measurements or assessment were not documented on the comprehensive assessment.

Upon patient record review, 1 of 14 (Patient #8) 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: • Actual or potential drug interactions • Effectiveness of drug therapy • Drug therapy currently associated with laboratory monitoring Patient #8: Oxygen 2 Liters per NC was noted on the initial RN assessment dated 07/18/25 and the initial plan of care. However, oxygen was not listed on the medication profile.

Upon patient record review, 1 of 14 (Patient #1) 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 #1: The Bereavement assessment was completed on 02/05/26 which was greater than 5 days after the admission date of 01/30/26.

Upon client record review, 2 of 14 (Patient #2,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2:Wound care was ordered per the plan of care 3 x week. During the week of 01/18/26 through 01/24/26, the wound care was documented as "not addressed" on 01/23/26. Patient #9:The plan of care dated 10/22/25 showed safety interventions included a "volunteer to provide support, socialization, and respite". However, there was no volunteer provided. Documented in the SN comprehensive assessment at admission was that the patient transferred hospices in order to receive a PT consult. Additionally, a PT visited the patient on 10/21/26 and 11/18/25, but there was no evidence of an order for PT or that PT was part of the plan of care.

Upon patient record review, 4 of 14 (Patient #2,#3,#7,#8) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #2 On the aide care plan dated 12/31/25 the duties of make bed, change linens, transfer and reposition were assigned "as needed.". Patient #3 The aide care plan dated 01/25/26 had assigned tasks of shower every visit and "bed bath as needed if too weak to shower." Aide is not able to make decision if patient is "too weak". Additionally, assist with bedside commode was assigned as needed. Patient #7 The aide care plan written 01/14/26 listed assigned duties of shave, make bed, and assist with transfer as "as needed". Patient #8 The aide care plan written 07/18/25 listed duties of making bed, change linens, and incontinent care as "PRN".

Upon patient record review 1 of 14 (Patient #9) 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 #9: An aide supervisory visit was completed on 10/28/25 and 11/17/25 which was greater than 14 days.

Upon patient client record review, 2 of 14 (Patient #5, #12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5:The consent, dated 01/23/26, was not signed by the patient and there was no evidence the relationship of the signatory was documented. Additionally, there was no evidence a request or declination for receipt of the Patient Notification of Non-Covered Services was documented. Patient #12: On the Admission Consent signed 05/05/25, there was no evidence the Notification of non-covered services was addressed as evidenced by the request or declination not checked.

Upon patient client record review, 2 of 14 (Patient #8,9) 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 #8: Wound care was ordered on the plan of care dated 01/14/26 specifically to, "clean the wound with WC, pat dry, apply calcium alginate and cover with a foam dressing". However, there was no evidence the SN followed the individualized plan of care due to lack of detailed documentation as evidenced by documentation on 01/15/26, "wound cleaned and new dressing placed on bottom foot", on 01/22/26, "wound care completed to L foot", and on 01/29/26, "wound care completed." Patient #9:A pain screening was completed as part of the SN comprehensive and HOPE assessment on 10/19/25 and documented as, "No pain reported". However, the PAINAD was also completed and pain was rated 4/10, but there was no other evidence the patient was experiencing pain.

Upon client record review, 2 of 14 (Patient #11,#12) did not have evidence that the discharge summary includes all required information. Patient #11, #12: There was no evidence the discharge summary included a summary of the patient's stay, and other documentation to assist with post--discharge continuity of care.

Upon patient record review, 2 of 13 (Patient #6, 9) 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 #6 Oxygen 1-5 LPM via nc prn on POC 9/15/22. No prn reason listed on medication profile. Patient #9 Oxygen 4L via NC cont noted on SN assessment 11/2/22. Not listed on medication profile.

Upon patient record review, 2 of 13 (Patient # 6, 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 #6 Oxygen 1-5 LPM via nc prn on POC 9/15/22. No prn reason listed on plan of care. Patient #9 Oxygen 4L via NC cont noted on SN assessment 11/2/22. Not listed on plan of care.

Upon client record review, 3 of 13 (Patient #3, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 12/30/22 SN visit documents wound care provided including optifoam to sacral stage 2 after cleansing with wound cleanser. There is no evidence of order for application of optifoam in wound care. Patient #10: POC dated 2/1/23 No evidence of orders for disciplines who provided visits: No frequencies listed on POC for SN, Aide, CH and MSW. SN made visit on 2/1,2/3, 2/7, MSW made visits 2/2 and 2/11, CH made visit 2/8/23. Patient #11: Chaplain ordered 1mo2 on POC dated 10/28/22. No visit made in October.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During SN visit on 2/21/23, SN failed to maintain infection control procedures by placing clean equipment back on soiled barrier.

Upon patient record review, 3 of 13 (Patient #4, 10, 11) 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 #4: Aide care plan dated 12/13/22 assigns both bed bath and shower. Patient #10: Aide care plan dated 1/27/23 assigns Complete BB, Footcare, Shampoo and oral care with a range of freq of 2-3 x week when aide is going 5 times per week. Patient #11: Aide care plan dated 12/28/22 assigns tasks as PRN: Dress, comb hair, footcare, nail care, and shampoo.

Upon patient record review 5 of 13 (Patient #3, 4, 7, 12, 13) 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 #3: Aide careplan dated 12/2/22 assigns shampoo and linen change for 1xwk, Aide performed the tasks two times per week during the period of 1/3-1/24/23. Patient #4: POC dated 1/19/23 aide ordered 3xweek. Aide performed visits 2xweek 1/22/23 and noted third visit not made due to aide illness- not a valid reason for missed visit. Patient #7: Aide careplan dated 11/9/22 assigns 1xweek foot care, nail care and shave. The aide performed 2x week from 11/19-11/23. Patient #12: POC dated 8/22/22 Aide ordered 5x week, No visit on 8/23, 4 visits completed this week and no evidence of missed visit. Patient #13: POC dated 1/13/23, Aide ordered 5xweek, Visits performed 1/13, 1/14/23, 1/17, 1/19 and 1/25/23 which is 2xweek. No evidence of missed visits or orders to change frequency.