Every finding on record at Ultimate Great Care Hospice Inc

Upon patient record review, 3 of 14 (Patients #1,2,3) 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: During medication reconciliation in patient home, patient has been taking fish oil and Vitamin D3. These meds were not included on the hospice medication profile. Patient #2: During medication reconciliation in patient home, the hospice medication profile indicated Glucosamine 200 mg 4 caps daily and patient is taking 500mg BID. Also, medication profile indicated Turmeric 500 mg 2 caps daily and patient is taking 4 caps daily. Patient #3: During medication reconciliation in patient home, the hospice medication profile indicated Multivitamin (MVI) daily. The patient is taking MVI with minerals daily.

Upon patient record review, 6 of 14 (Patients # 4,5,9,10,11,12) 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 #4: No contact information for bereaved family member. Patient declined visit during the first 5 days of care, the bereavement risk assessment was not completed until 3/3/26. Patients 5,9,10,11,12: Patient declined visit during the first 5 days of care, the bereavement risk assessment was not completed until 3/3/26.

Upon patient record review, 2 of 14 (Patients #2,3) 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 medications and treatments. Patient #2: During medication reconciliation in patient home, the hospice plan of care indicated Glucosamine 200 mg 4 caps daily and patient is taking 500mg BID. Also, plan of care indicated Turmeric 500 mg 2 caps daily and patient is taking 4 caps daily. Patient #3: During medication reconciliation in patient home, the hospice plan of care indicated Multivitamin (MVI) daily. The patient is taking MVI with minerals daily.

Upon patient record review, 4 of 14 (Patients #1,5,7,8) 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 equipment and supply needs. Patient #1: This patient had a nebulizer machine, wheelchair, walker and cane. These were not included on the plan of care. Patient #5: This patient had a cane. This was not included on the plan of care. Patient #7: The record reflected that this patient had a walker, wheelchair, shower chair, nebulizer machine, suction machine and oxygen. These were not included on the plan of care Patient #8: The record reflected that this patient had a walker, nebulizer machine, suction machine, and oxygen. These were not included on the plan of care.

Upon client record review, 2 of 14 (Patients #3,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The POC listed LVN visit frequency of, 1 X's per week. For benefit week 2/1/26 and 2/8/26 the LVN did not visit, instead it was an RN that made a visit for these weeks. Patient #8: The POC listed Social Worker (SW) visit frequency of, 1 X's per month. There were no visits provided by SW in February 2026.

Upon patient record review, 2 of 14 (Patients #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 Patients #13,14: The 13-month bereavement plan of care in the EMR is not being fully populated to reflect required follow-up frequencies. Documentation is currently limited to ad-hoc mailing notes, rather than a structured, scheduled plan of care.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient or pseudo patient: ·Reading and recording temperature-rectal ·Toileting and elimination-bedpan

Upon contract review, 1 of 4 (Fidelity Care contract PT/OT/ST) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Furnished in a safe and effective manner by qualified personnel

Upon patient client record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Additionally, the effective date to begin hospice was left blank in space provided on the form. Patients #2,3,4,5,6,7,8,9,10,11,12,13,14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information.

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

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the update to the comprehensive assessment considers changes that have taken place since the initial assessment and include the patients progress toward desired outcomes. For example: on review or RRHV#1, RRHV#2, and RRHV#3 the plan of care lacked progress toward goals as the goals and interventions appeared unchanged IDG to IDG over an extended period of time. In RRNHV#4 the care plans remained similar over time with short term goals such as patient/family will verbalize understanding of safety prevention interventions and PCG will be able to show return demonstration of safe active/passive range of motion. These goals were opened on admission and remain un-resolved at survey nearly a year later. In review of RRNHV#10 the goals for wound care were noted to be achieved by 14 days but were opened in June and remain unaddressed to survey. These observations were reviewed with the QAPI LVN and DPCS.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect the patient and family goals based on the problems identified in the comprehensive assessments that were specific, measurable, and time bound. On review of RRHV#1 it was noted that all goals were not individualized and time bound as all target dates for all goals were for the same date at the end of the month. In RRHV#3 there were no goals for nutrition even though there were nutritional interventions, and all goals established had the same target dates and were not individualized based on the patient needs. Similar issues with all target dates being the same for all goals, and not individualized per the patients needs were noted in RRNHV#7 and RRNHV#8. In RRNHV#9 and RRNHV#10 there were goals that were not measurable such as optimal blood sugar management for patient comfort while on hospice service. These observations were reviewed with the QAPI LVN, and the DPCS.

Observed in Record Review. In 4 of 10 patient records reviewed, for active records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 the patient was being seen by the Chaplain and Social Worker, yet there were no spiritual or psychosocial care plans to guide the care given. Further the patient had documentation of an eye infection, and a fall with skin tears however the documented issues were not reflected in the care plans. In RRHV#1 the patient was receiving visits from the Chaplain but no spiritual care plan. In RRHV#3, and RRNHV#4 there were no spiritual or psychosocial care plans noted on the plan of care. These observations were reviewed with the Administrator, DPCS, and QAPI LVN.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the staff follow the infection control and prevention activities it had planned. On home visit for RRHV#3 the aide failed to remove gloves and perform hand hygiene after performing perineal care before to moving on to another assigned task. After performing perineal care the aide changed the water and continued the bed bath and changing sheets on the bed but did not perform hand hygiene per policy. This observation was reviewed with the QAPI LVN.

Observed in Record Review. In 2 of 8 patient records reviewed, where hospice aide services were provided, the organization failed to ensure the aide receive written patient care instructions specific to the tasks assigned. For example: on RRNHV#6 and RRNHV#10 the patient had wounds with wound care dressings and bathing assigned, however there were no specific instructions to the aide on how to handle the dressings during the bathing process. This observation was reviewed with the QAPI LVN, and the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, for active records, the organization failed to ensure the physician review the clinical information for each hospice patient and provide a written certification that includes all of the required elements. For example: on review of the CTI's for RRHV#2 each CTI read very similar to one another and lacked current subjective and objective medical findings. This observation was reviewed with the Administrator, DPCS, and QAPI LVN.

Observed in Record Review. In 2 of 10 patient records reviewed, for active records, the organization failed to ensure the patient record contain all information that reflects the patient's care, treatment, or services. For example: on review of RRNHV#7 the MSW conducted the initial psychosocial assessment and initial bereavement risk assessment yet the documentation remained incomplete in the record at time of survey and not in accordance with organization policy for submission. In RRNHV#10 the patient had a wound with dressing changes ordered, yet the documentation in the record failed to contain pertinent clinical information related to the wound care treatments, as documentation stated wound care done as ordered and wound care rendered to pressure ulcer on left thigh. Patient tolerated well. The documentation failed to specify what treatment was provided to the patient, and the former statement did not note the patient's response to the treatment. These observations were reviewed with the QAPI LVN and the DPCS.