Every finding on record at St. Markoss Hospice Inc.

Upon patient record review, 2 of 14 (Patients #6,7) 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. Patients #6 & 7: The Plan of Care indicated the patient is Diabetic II with orders to check blood sugars before meals and at bedtime. There was no evidence of problems, goals, or interventions related to the Endocrine system.

Upon client record review, 4 of 14 (Patient #1,4,5,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: MSW and SC visit frequency indicated Initial visit within 5 days of Start of Care (1/13/26). The MSW made visits on 2/12/26 , 3/2/26 & 4/1/26 and the SC made visits on 2/8/26 & 3/7/26 without updated orders. Patient #4: MSW and SC visit frequency indicated Initial visit within 5 days of Start of Care (1/30/26). The MSW made visits on 2/18/26 & 3/11/26 and the SC made visits on 3/1/26 & 4/7/26 without updated orders. Patient #5: MSW Visit frequency indicated Initial visit within 5 days of Start of Care (3/10/26). The MSW a made visit on 4/9/26 without updated orders. Patient #6: MSW Visit frequency indicated Initial visit within 5 days of Start of Care (3/19/26). The MSW a made visit on 4/19/26 without updated orders.

Upon personnel record review, 1 of 11 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Reading and recording temperature (rectal) ·Toileting and elimination (urinal)

Upon patient record review 1 of 14 (Patient #1) 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: The POC listed Aide visit frequency of, 2 X's per week (1/13/26). For 1st Benefit Week there was only 1 visit on 1/16/26 .

Upon patient client record review, 1 of 14 (Patient #11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 11: The Election Statement did not include the date designated for "benefits begin on". This area of form was left blank.

Upon client record review, 2 of 14 (Patients #11, 12) did not have evidence that the discharge summary includes all required CMS information as follows: • The patient's current plan of care

Upon patient record review, 2 of 14 (Patient #1,#3) 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: As observed during the home visit medication reconciliation the patient is using artificial tears three times a day since 3/21/23. The medication profile did not contain artificial tears. Patient #3: The medication profile included Miralax. There was no evidence the order contained a diluent and the direction is unclear.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: The patient was admitted with a diagnosis COPD. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems related to COPD.

Upon patient record review, 4 of 14 (Patient #1,#3,#9,#10) 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 #1: During the home visit medication reconciliation the patient is using artificial tears three times a day. There was not an order for Artificial tears. Patient #3: The plan of care contained Mirlax. There was not evidence the order contained a diluent and the direction is unclear. Patient #9: The wound care order dated 9/11/22 on the plan of care doesn't identify who is to perform the wound care "...cleanse with wound cleanser spray, apply Xerofoam, cover with gauze and ABD pad wrap, with kerlix secure with tape daily until healed". Patient #10: The wound care order dated 12/7/22 does not identify who is to perform wound care to the sacrum on the plan of care.

Upon patient record review, 2 of 14 (Patient #3,#4) 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 equipment and supply needs. Patient #3: The medical record indicated the patient was using a nebulizer. The plan of care did not contain a nebulizer. Patient #4: The medical record indicated the patient was using Bipap. The plan of care did not contain Bipap.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: The medical record indicated the patient was on Eliquis and there was no evidence of bleeding precaution on the aide plan of care.

Upon patient client record review, 3 of 14 (Patient #6,#12,#13) 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 #6: The Hospice Medicare Election statement does not clearly identify why the patient is unable to sign the election of benefit The line to write in the reason why the patient is unable to sign is left blank. Patient #12: The Hospice Medicare Election statement does not clearly identify the patient’s choice for the effective date of election. The line to write in the effective date of election is left blank. Patient #13: The Hospice Medicare Election statement does not clearly identify the patient’s choice for the effective date of election. The line to write in the effective date of election is left blank.

Upon patient client record review, 4 of 14 (Patient #3,#9,#10,#14) 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 #3:The nursing comprehensive assessment dated 10/29/22 was not signed or dated by the clinician. Patient #9: The nursing visit note narrative dated 12/18/22 contained documentation that was not clear "patient treated with natural glass for chest pain", "assessment performed in a bottle size been taken", "**** you changes in the patient's condition". In addition the note not signed by the clinician. Patient #10: The bereavement risk assessment dated 12/10/22 was completed by the social worker but not signed until 6/19/23. Patient #14: The nursing narrative on the comprehensive assessment dated 2/14/23 contained the wrong name of the hospice agency. "Patient admitted to Loyal Hospice Care...".