Every finding on record at Stillwater Hospice LLC

Upon patient record review 10 of 23 (Patient #1,2,3,11,13,14,15,16,17,18) 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 1: Initial RN assessment dated 03/29/23 does not show evidence of a comprehensive pain assessment. Patient 2: Initial RN assessment dated 01/03/24 does not show evidence of a comprehensive pain assessment. Patient 3: Initial RN assessment dated 05/06/25 does not show evidence of a comprehensive pain assessment. Patient11: Initial RN assessment dated 07/23/25 does not show evidence of a comprehensive pain assessment. Patient 13: Initial RN assessment dated 03/04/25 does not show evidence of a comprehensive pain assessment. Patient 14: Initial RN assessment dated 12/03/25 does not show evidence of a comprehensive pain assessment. Patient 15: Initial RN assessment dated 11/30/24 does not show evidence of a comprehensive pain assessment. Patient 16: Initial RN assessment dated 04/10/25 does not show evidence of a comprehensive pain assessment. Patient 17: Initial RN assessment dated 06/06/25 does not show evidence of a comprehensive pain assessment. Patient 18: Initial RN assessment dated 05/15/25 does not show evidence of a comprehensive pain assessment.

Upon patient record review, 3 of 23 (Patient #9,11,16) 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 9: The current medication record includes an order for MiraLax powder, order does not include diluent. Corrected on site, medication record updated. Patient 11: The current medication record includes an order for triamcinolone acetonide external cream 0.1%, order does not indicate a site of application. Corrected on site, medication record updated. Patient 16: The current medication record contains orders for acetaminophen 500 (2) tab(s) twice daily and acetaminophen 325mg 2 tab(s) every 6 hours prn for pain/fever. There is no directive for maximum daily limit of acetaminophen in all forms. Corrected on site, medication record updated.

Upon patient record review, 7 of 23 (Patient #2,4,7,9,10,14,17) 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. Coordination/Clinical Notes: Patient 2: The current POC includes orders for Plavix. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 4: The current POC includes orders for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions Patient 7:The current POC include(s) orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 9: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 10:The current POC include(s) orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 12: The current POC includes orders for Eliquis & Plavix. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 14: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 17: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions.

Upon patient record review, 3 of 23 (Patient #9,11,16) 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 9: The current POC includes an order for MiraLax powder, order does not include diluent. Corrected on site, POC updated. Patient 11: The current POC includes an order for triamcinolone acetonide external cream 0.1%, order does not indicate a site of application. Corrected on site, POC updated. Patient 16: The current POC includes orders for acetaminophen 500 (2) tab(s) twice daily and acetaminophen 325mg 2 tab(s) every 6 hours prn for pain/fever. There is no directive for maximum daily limit of acetaminophen in all forms. Corrected on site, POC updated.

Upon patient record review, 12 of 13 (Patients #1, #2, #3, #4, #5, #6, #8, #9, #10, #11 #12 and #13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1, #2, #3, #4, #5, #6, #8, #9, #10, #11 #12 and #13: Did not have imminence of death on comprehensive assessment. The admission RN did not use dedicated drop down box for this template/assessment in the EMR that pulls information to IDG POC.

Upon patient record review, 2 of 13 (Patients #1 and #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: Patient #1 and 3: Oxygen was not included on medication profile.

Upon patient record review, 2 of 13 (Patients #1 and #3) 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 #1: This patient had a CPAP machine and side rails for bed. These items were not included on the Plan of Care. Patient #3: This patient had an oxygen concentrator. This item was not included on the Plan of Care.

Upon client record review, 2 of 13 (Patients #1 and #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The POC listed Skilled Nursing visit frequency of 3 X's per week. For first Benefit Week, there were only 2 visits on 10/27 and 10/28 only. Patient #7: The POC listed Skilled Nursing visit frequency of 7 X's per week. For first Benefit Week, there were only 6 visits on 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29 only.

Upon patient record review 6 of 10 applicable (Patients #1, #2, #3, #8, #9 and #10) 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 Patient #1: The POC dated 10/27/22 listed an Aide visit frequency of 3x per week. There was only one visit made that week on 10/27/22 only. The visit frequency was not met for this week. Patient #2: The POC dated 07/01/22 listed an Aide visit frequency of 2x per week. For 1st Benefit Week, there was only one visit made on 7/01. For Benefit Week 8/14 to 8/20, there were 3 visits made on 8/16, 8/17 and 8/18/22. Patient #3: The POC dated 09/16/22 listed an Aide visit frequency of 3x per week. For 1st Benefit week, there was only one visit made on 9/16/22. Patient #8: The POC dated 08/03/22 listed an Aide visit frequency of 2x per week. For 1st Benefit week, there were 3 visits made on 10/3, 10/5 and 10/7/22. For 2nd Benefit Week there were no visits made. Patient #9: The POC dated 08/19/22 listed an Aide visit frequency of 2x per week. There was only one visit made on 8/19/22 for that week. Patient #10: The POC dated 05/01/22 listed an Aide visit frequency of 1x per week. For 1st Benefit Week, there were 3 visits made on 5/2, 5/5 and 5/6/22. For 2nd benefit week and on-going there were 2 visits per week.

Upon client record review, 1 of 1 applicable (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: Did not have evidence that the Copy of Signed Consents for care and Copy of the Certification of Terminal Illness were sent/faxed to receiving hospice at time of transfer.

Upon personnel record review, 1 of 4 applicable (Personnel #10) did not have evidence the hospice obtained a criminal background check and National sex offender registry check on all contracted individuals who have direct patient care and access to patient records.