Every finding on record at Trinity Hospice 1, LLC

Upon patient record review 1 of 14 (Patient #14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Pt #14 - Pt admitted 5/29/24. SC assessment completed 6/24/24 - more than 5 days.

Upon patient record review, 2 of 19 (Patient #6, #18) 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 Pt #6 - Pt on oxygen. No evidence of oxygen on Medication profile (Corrected on site) Also, upon home visit noted pt was placed on Miralax on 7/1/24. Pt's daughter has not picked up the mediation - today 7/17/24. Pt # 18 -Upon home visit, SNF MAR did not match hospice MAR, facility was missing order of 10/23/23 Fexofenadine 60 mg tab 1 time day for allergies; Mirtazapine 15 mg 2/12/24 1 tab tid; Docusate 200m by mouth for bowel regime(Corrected on site)

Upon patient record review, 3 of 14 (Patient #6, 7, 8) 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. Pt #6 - No evidence of order for pt's oxygen in record (Corrected on site) Pt #7 - Order for oxygen read O2 2l/min per nc/face mask for SOB. No evidence of prn or continuous (Corrected on site) Pt #8 - order for oxygen reads 2-5 l/min gas respiratory (inhalation) every 1 min as needed for SOB. no evidence of nc or mask (Corrected on site)

Upon client record review, 2 of 19 (Patient #10, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt # 10-order on chart for PT to evaluate and treat as appropriate 6/19/24. No evidence that PT evaluation was done. Facility stated that auth for insurance was done and received approval on July 3rd. Facility states he will be seen this week. As of 7/17/24, no therapy visit completed. Pt # 13 - no evidence of an order to discontinue wound care to patient's R foot area after 7/5/24 (Corrected on site)

Upon patient record review, 1 of 14 (Patient #10) 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 Pt # 10 - Pt is on Xarelto, 1xday. No evidence that bleeding precautions are on aide plan of care. POC does include shaving patient every visit.(Corrected on site)

Upon personnel record review, 6 of 14 (Personnel #1, 2, 3, 4, 6, 11 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. (All Corrected on Site)

Upon client record review, 1 of 19 (Patient #13) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Pt #13 - Wound care is ordered for this patient. POC does not identify who is responsible for performing this care. To abdominal fold and right foot, - cleanse with wound cleanser and pat dry with non sterile gauze. cover with ABD and secure with tape.

Upon personnel record review, 1 of 14 (Personnel # 11) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #11- SC - No evidence of credentials, ordination, or theology degree in personnel file as listed as job requirements. (Corrected on site)