Every finding on record at Universal Hospice Group

Upon patient record review, 2 of 14 (Patient #5,#8) 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#5: During the home visit it was confirmed patient is taking Metformin ER 500mg take 2 daily. There is no evidence of this medication on the hospice medication profile. Patient#8: During home visit it was confirmed patient taking Mounjaro 7.5mg/0.5ml inject 1 x week. There is no evidence of this medication on hospice medication profile.

Upon patient record review, 2 of 14 (Patient #6,#8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#6: During record review the RN frequency is ordered for 1 visit every 2 weeks. There was no evidence of an RN visit from 1/16/26 to present which is greater than every 15 days. Patient#8: During record review the RN frequency is ordered for 1 visit every 2 weeks. There was no evidence of an RN visit after 1/29/26 to present which is greater than every 15 days.

Upon patient record review, 2 of 14 (Patient #5,#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. Patient#5: During home visit is was confirmed that patient was taking metformin 500 ER take 2 daily. There is no evidence of an order for this medication. Patient#8: During home visit it was confirmed patient taking Mounjaro 7.5mg/0.5ml inject 1 x week. There is no evidence of on order for this medication.

Upon client record review, 4 of 14 (Patient #2, #6,#7,#8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: The record indicates patient had a wound to right lower extremity on 12/12/25 and is documented as healed on 12/17/25. The nurse documents performing a dressing change however, there is no evidence of an order for cleansing wound, applying triple antibiotic ointment, and covering with 4x4. Patient#6: During record review the RN frequency is ordered for 1 visit every 2 weeks. There was no evidence of an RN visit from 1/16/26 to present. During the survey process RN entered late documentation for visits on 2/13/26 and 2/27/26. However this is in violation of agency policy which states documentation is to be completed within 7 days of visit. There is no evidence of RN visit between 1/16/26 to 2/13/26. Patient#7: The record indicates Spiritual frequency is 1 visit per cert period. There is evidence spiritual documented a visit on 12/24/25 as a recert visit, however, documentation states this was a telehealth visit not an in person visit as ordered. Patient#8: During record review the RN frequency is ordered for 1 visit every 2 weeks. There was no evidence of an RN visit after 1/29/26 to present.

Upon patient record review, 2 of 14 (Patient #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • 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: The record indicates patient passed 12/15/25. According the plan of care mailing are to be sent on month 1, 3, 6, 9, 12, and 13. There is no evidence the 1 month letter that was due 1/15/26 was sent. Patient#14: The record indicates patient passed 03/04/25. According the plan of care mailing are to be sent on month 1, 3, 6, 9, 12, and 13. There is no evidence of mailings being sent at 6 months due on 9/04/25 or at month 9 due on 12/4/25.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient#2: The medical record indicates that LPN entered problems, goals ,and interventions related self care deficit for ADLs on 11/28/25 to the plan of care. These problems, goals, and interventions remain active. Patient#5, #10: The medical record indicates that LPN entered problems, goals, and interventions related to patient being full code to the plan of care. These problems, goals, and interventions remain active. This is not within LPN scope or practice.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient#1: During record review initial CTI for benefit period 1 contained a physician narrative that only stated "no update". No patient or clinical information was in the physician narrative.

Upon patient client record review, 1 of 14 (Patient #2) 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#2: The order for DME on the plan of care states patient has a walker. There is no evidence of Wheelchair on the DME order. However, MSW documents on 12/2/25 that patient is wheelchair bound and non ambulatory.

Upon patient record review, 2 of 11 (Patient #2, #9) 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 #2: Oxygen 2L/M PRN SOB was ordered upon admission. Oxygen was not included on the medication profile. Patient #9: Oxygen 2L/M was ordered upon admission. Oxygen was not included on the medication profile.

Upon patient record review, 2 of 11 (Patient #2, #6) 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 #2: Patient was prescribed insulin for Diabetes since admission. There was no evidence of blood sugar ranges to notify MD or frequency of blood sugars to be obtained included in the care plan. Patient #6: Patient was prescribed insulin for Diabetes since admission. There was no evidence of blood sugar ranges to notify MD included on the care plan.

Upon client record review, 1 of 11 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: Nurse visit frequency was ordered upon admission 1xweekly. There was no evidence of a nurse visit completed during the week of 2/26/23.

Upon patient record review, 1 of 11 (Patient #10) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #10: The bereavement plan of care included a 1 month letter of support to be mailed due 12/5/22 and a 3 month letter of support to be mailed due by 2/6/23. There was no evidence that these letters were mailed. The medical record indicated past due on both of these interventions.

Upon patient record review 2 of 11 (Patient #6, #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 #6: Aide frequency was ordered upon admission 1xweekly. There was no evidence of an aide visit completed during the weeks of 2/17/23, 2/19/23, or 2/26/23. Patient #9: Aide frequency was ordered upon admission 3xweekly. There was aide visits missing x1 during the week of 2/26/23. Additionally, the aide plan of care indicated tasks to be completed every visit including pajamas and dress every visit. On aide visit dates 2/2/23, 2/14/23, 2/23/23, 2/25/23, 2/28/23, 3/2/23, and 3/7/23, the aide failed to document provision of care of tasks pajamas and dress every visit.

Upon patient record review, 6 of 11 (Patient #1, 2, 3, 4, 5, 7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: There was no evidence in the medical record of a physician narrative for the recertification BP#2 dates of 12/11/22 to 3/10/22. Patient #2: Recertification for BP #8 for dates 2/19/23 to 4/19/23, there was no evidence of a verbal certification order obtained. The recert was signed by the MD on 3/2/23. Patient #3: Recertification for BP #11 for dates 1/6/23 to 3/6/23, there was no evidence of a verbal order certification obtained. The recert was signed by the MD on 1/22/23. Patient #4: Recertification for BP #7 for dates 12/21/22 to 2/18/23, there was no evidence of a verbal certification order obtained. The recert was signed by the MD on 1/22/23 Recertification for BP #8 for dates 2/19/23 to 4/19/23, there was no evidence of a verbal order obtained. the recert was signed by the MD on 3/2/23. Patient #5: Recertification for BP #3 for dates 12/13/22 to 2/10/23, there was no evidence of a verbal certification order obtained. The recert was signed by the MD on 1/22/23. Patient #7: Recertification for BP #10 for dates 1/10/23 to 3/10/23, there was no evidence of a verbal certification order obtained. The recert was signed by the MD on 1/22/23.

Upon patient client record review, 11 of 11 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) 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 #1, #3, #4, #5, #7, #8, #9: Upon admission, the consent for election of hospice did not include the notification of the patient's right to receive the addendum of noncovered services or the QIO contact information. Patient #2, #6, #10, #11: Upon admission, the consent form for election of hospice did not include the notification of the patient's right to receive the addendum of noncovered services or the QIO contact information and the date of hospice election was blank.