Every finding on record at Ss Hospice Care, Inc.

Upon patient record review, 1 of 14 (Patient #1) 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: Patient record indicated on oxygen as a treatment. Oxygen was not included on the medication profile. Additionally, during medication reconciliation on home visit, the hospice medication profile indicated Albuterol 0.83% 1 vial every 6 hours. The board and care included albuterol every 4 hours.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicated patient takes oral metformin 500 mg twice daily. There was no evidence of problems, goals, or interventions related to the endocrine system.

Upon patient record review, 1 of 14 (Patient #1) 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. Patent #1: During medication reconciliation on home visit, the hospice plan of care indicated Albuterol 0.83% 1 vial every 6 hours. The board and care included albuterol every 4 hours on their med profile.

Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Reading and recording rectal temperature ·Toileting and elimination with bedpan

Upon patient client record review, 2 of 14 (Patients #4,10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #4: The election statement indicated effective start date of 9/16/25. The hospice start of care in the record was 9/17/25. Patient #10: The election statement indicated effective start date of 9/8/25. The hospice start of care in the record was 9/10/25.

Upon patient client record review, 1 of 14 (Patient #2) 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 #2: The CTI included RN and Medical Director note/narrative. The RN note indicated the patient was 77 years old and the Medical Director narrative indicated the patient age was 78 years old. Correct age was 78 years old per the patient.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, SN frequency 2x/week to start 2nd week of certification period. No order for initial nursing assessment.

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. Patient #1, 2, 3, RN did not sanitize hands every time RN went into nursing bag.

Upon patient client record review, 5 of 5 (Patient #1,2,3,4,5) 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 1,2,3,4,5, Admission paperwork had typed name for signature with signature not legible over typed name.