Every finding on record at Stars Palliative & Hospice Care, Inc.

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#5,#6,#7,#8,#10,#11) 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 • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1: Polyethylene glycol was on the medication profile, but there were no instructions for a diluent. COS by adding the diluent instructions. Triamcinolone was on the medication profile but without evidence a specific area of application (route) was listed. COS by an order to discontinue medication. Additionally, The face-to-face documented by the NP on 12/13/25 indicated the patient was dependent on a suppository every other day for bowel movement, but there was no suppository on the medication profile. COS by adding to medication profile. Patient #2:Ketoconazole topical was listed on the medication profile but there was no indication of the area of application. COS by adding the area of application to the med profile per the order. Patient #3: Nystatin topical was listed on the medication profile, but there was no evidence of a specific area of application. COS by adding the area of application to the med profile per order. Patient #5: The comprehensive assessment dated 10/28/25 indicated the patient was taking using Voltaren gel and 650mg of Tylenol to control pain, but there was no evidence that these medications were included on the medication profile. Patient #6: The initial plan of care indicated the patient was using 2L of Oxygen per NC, but there was no evidence of oxygen listed on the medication profile. COS by adding Oxygen to the med profile per the order. Patient #7: Polyethylene glycol was listed on the medication profile without evidence of a diluent. Additionally, Hydrocortisone topical was on the medication profile without evidence of a specific route of application. COS by adding the diluent instructions for Polyethylene glycol and the route for the hydrocortisone per orders. Patient #8: Polyethylene glycol was listed on the medication profile without evidence of a diluent. COS by adding the diluent instructions per the order. Patient #10: The face-to-face dated 11/26/25 and the initial plan of care indicated the patient was using oxygen at 2L per NC PRN, however, oxygen was not listed on the medication profile. COS by adding O2 to the medication profile per orders. Patient #11: Per the comprehensive assessment and initial plan of care, the patient was using 2 L O2 per NC, however, there was no evidence of oxygen 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 patient was admitted on 09/04/25, but the initial bereavement assessment was completed on 09/11/25 which was > 5 days.

Upon patient record review, 4 of 14 (Patient #1,#2,#7,#8) 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 #1: The patient's hospice diagnosis was Cognitive Disorder with Lewy Body Dementia, however the Neuro care plan was discontinued on 07/01/25. Patient #2: The patient's hospice diagnosis was Cerebral Vascular Disease, however there was no evidence of a cardiac or neuro care plan. Patient #7: The patient's hospice diagnosis was Senile Degeneration, however there was no evidence of a Neuro care plan. Patient #8: The patient's hospice diagnosis was Cerebral Infarct, however there was no evidence of Neuro or Cardiac care plans.

Upon patient record review, 1 of 14 (Patient #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 #5: The comprehensive assessment dated 10/28/25 indicated the patient was using Voltaren gel and Tylenol 650 mg, but these medications were not included as part of the plan of care.

Upon patient record review, 2 of 14 (Patient #8, #12) 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 #8: On 10/24/25, the NP documented the patient was "wheelchair dependent", but there was no evidence of a wheelchair included in the plan of care. COS by adding DME to the plan of care. Patient #12: The RN notes dated 10/17/24 and 05/27/25 indicated the patient was transferred to a wheelchair, and on 06/06/25, the SW note indicated the patient's spouse was concerned about pending discharge due to the hospice supplying the hospital bed. However, there was no evidence the hospital bed or the wheelchair were part of the plan of care.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The plans of care dated 11/13/25 and 11/26/25 indicate SW frequency is 1 x month, but there was no evidence of a visit in November 2025. COS by updating the plan of care to reflect patient needs.

Upon patient record review, 2 of 14 (Patient #13,#14) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13, #14: There was no evidence of a bereavement plan of care.

Upon patient record review, 1 of 14 (Patient #7) 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. Patient #7: Aspirin and Plavix were on the medication profile, but there was no evidence of bleeding precautions listed on the aide care plan. COS by adding bleeding precautions to the aide care plan.

Upon patient record review 2 of 14 (Patient #7,#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 #7: On 12/05/25,12/08/25 and 12/10/25 there was no evidence the aide assisted with tooth brushing, or turning and repositioning as assigned, and there was no evidence of documentation as to the reason the tasks were not completed. Patient #9: The aide frequency as listed on the plans of care dated 11/26/25 and 12/09/25, was 1 x week. However, on the week of 11/30/25 - 12/6/25 the aide visited twice on 12/02/25 and 12/05/25, and on the week of 12/07/25 to 12/13/25, the aide visited twice, 12/09/26 and 12/11/25. COS by updating the plan of care for current frequency.

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. A review of the governing body minutes indicated volunteer hours are equal to 1.48% of total patient care hours for YTD 2025. The 2024 annual volunteer percentage was less than 1%.

Upon patient client record review, 4 of 14 (Patient #4,#7,#11,#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 #4: The Hospice Election, page 2/9, dated 10/14/25 had no evidence that financial responsibility was addressed as evidenced by no documented responses regarding Medicare, Medicaid, Commercial or Private Pay. Patient #7: Per the hospice election form the patient elected the Notification of Hospice non-covered items on 01/29/25, but there was no evidence this was provided. Patient #11: Per page 4/6 of the Hospice Election, there was no evidence the patient declined or elected an attending physician as evidenced by this are being left blank. Patient #12: Per the Hospice election dated 10/08/24, there was no evidence that the patient elected or declined the Notification of non-covered services as evidenced by this area being left blank.

Upon patient client record review, 1 of 14 (Patient #11) 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 #11: The discharge summary dated 05/20/25 indicated the patient revoked services and went to the hospital. However, the revocation document, which was signed on 05/20/25, indicated the patient discharged due to death which was documented as having occurred on 05/21/25.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: The effectiveness of drug therapy, Drug side effects. Actual or potential drug interactions. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that medication profiles were updated, and drug regimens occurred when new medications were ordered for patients. Clinical Record 4 On 9/14/22 the Skilled Nurse (SN) documented "reddened right ear; the caregiver reports patient slept on that side. SN gave the patient's aide zinc ointment to apply to it." There is an MD order dated 9/14/2022 that stated " Ok to use Barrier Ointment/Cream (zinc ointment). A review of the drug profile revealed zinc ointment/barrier cream was not added and there was no evidence that the medication was reviewed. During a joint record review, on 10/20/22, the Director of Nurses, stated, "the zinc ointment/barrier cream was not added to the medication profile".