Every finding on record at Unity Hospice of Greater Madison LLC

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care There is no evidence that the agency had completed a facility-based risk assessment.

Upon patient record review, 3 of 6 (Patient #1, #2 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Dimethicone/Zinc Oxide topical cream on the medication list did not have an application location. The order was correct. The Triple Antibiotic ointment 3x/day prn on the medication list didn't have an indication or an application location. The order was correct. Both were corrected on medication profile. Patient #2: Upon home visit observation, the Hyoscyamine, Milk Magnesia, Acetaminophen suppositories and Acetaminophen tabs were on the facility medication list but not on the hospice medication list. Corrected onsite. Patient #3: Upon review of the medication list the Sinemet said 1-1 1/2 tablets 3x/day. There was no instructions directing when the patient should take the different doses.

Upon patient record review, 2 of 6 (Patient #2 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 medications and treatments. Patient #2: Upon review of the facility medication profile it revealed Hyoscyamine, Milk Magnesia, Acetaminophen suppositories and Acetaminophen tabs. There was no evidence of an order for any of medications in the patient's hospice record. Corrected onsite. Patient #3: Upon review of order it said Sinemet 1- 1 1/2 tablets 3x/day. There was no instructions directing when the patient should take the different doses.

Upon observation during home visit 1 of 3, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: The aide put shoulder bag on the floor. The agency procedure given to the surveyor by the DPCS said "Never set the health care bag on the floor."

Upon patient record review 1 of 6 (Patient #3) 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 #3: The aide care plan said the aide was to weigh patient the 1st visit of each month and to change the patient linens each visit. The documentation did not reflect a weight was completed on the first visit of the month on visits 10/02/25 and 11/03/25. There was no documentation that the linens were changed on 09/25/25, 10/13/25, 10/13/25. On 10/16/25 the aide care plan was updated to say that the linens were to be changed the 1st visit of the week but there no documentation that linens were changed on the 10/20/25, 10/27/25 and 11/03/25 visits.

Upon client record review, 1 of 6 (Patient #5) 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. Patient #5: The 09/04/25 sacrum wound orders did not specify if the SNF staff or the hospice staff were to complete the wound care.