Every finding on record at Wondrous Love Hospice Care LLC

Upon patient record review, 3 of 14 (Patient #3,4,9) 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 3: Medications verified with family during home visit, stated patient has been taking aspirin 81mg daily for years. Aspirin is not on the hospice medication profile. Corrected on site. Patient 4: On the medication profile there is a medication Nystop 100,000 unit/gm, topical 4 times daily for redness and irritation. There is no directions for where to apply the medication. Corrected on site. Patient 9: On the medication profile there is a medication, MiraLAX daily as needed, there is no diluent.

Upon patient record review, 1 of 14 (Patient #8) 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 8: In the patient record there is an order for aspirin 81mg daily, there is not a risk for bleeding on the plan of care with goals and interventions. Corrected on site. Corrected on site.

Upon patient record review, 3 of 14 (Patient #3, 4, 9) 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 3: Medications verified with family during home visit, stated patient has been taking aspirin 81mg daily for years. Aspirin is not on the hospice plan of care. Corrected on site. Patient 4: On the current plan of care there is a medication Nystop 100000 unit/gm, topical 4 times daily for redness and irritation. There is no directions for where to apply the medication. Corrected on site. Patient 9: Patient 9: On the plan of care there is a medication, MiraLAX daily as needed, there is no diluent.

Upon client record review, 1 of 14 (Patient #10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 10: On the IDG note 10/10/25 there are missing signatures from the IDG team including the medical director, chaplain, MSW, and nursing.

Upon patient record review, 6 of 14 (Patient #1,2,4,5,9,10) 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 Patient 1: On the hospice aide plan of care there are orders to assist with clothing, complete bed bath, foot care: apply lotion to feet, nail care: wash under nails and file, oral care, partial bed bath, perineal care, shampoo, skin care: lotion to all extremities, these orders do not contain a frequency. Corrected on site. Patient 2: On the aide plan of care there are orders to assist with clothing, complete bed bath, foot care, nail care: clean under nails and file, oral care, partial bed bath, perineal care, shampoo, skin care: apply lotion to extremities after bed bath, these orders do not contain a frequency. Corrected on site. Patient 4: On the aide plan of care there are orders to assist with clothing, complete bed bath, foot care: wash with warm water and soap, pat dry ensuring dry between toes, nail care, oral care, perineal care, shampoo, shave, skin care: apply lotion to all extremities, face and back, these orders do not contain a frequency. Corrected on site. Patient 5: On the aide plan of care there are orders to assist with clothing, completed bed bath, foot care, nail care, oral care, partial bed bath, perineal care, shampoo, skin care, these orders do not contain a frequency. Corrected on site. Patient 9: On the aide plan of care there are orders to assist with clothing, complete bed bath, foot care: wash with warm water and soap, pat dry ensuring dry between toes and apply lotion, nail care: clean under nails and file, oral care, clean dentures, partial bed bath, perineal care, shampoo, skin care: apply lotion to all extremities, face, and back, these orders do not contain a frequency. Patient 10: On the aide plan of care there are orders to assist with clothing, complete bed bath, foot care: wash with soap and water, dry, apply lotion, nail care, oral care, partial bed bath, perineal care, shampoo, skin care: apply lotion to all extremities, chest and back, these orders do not contain a frequency.

Upon patient record review, 2 of 14 (Patient #1,8) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 1: On the RN assessment 11/19/25 the RN documented "wound care rendered as ordered" RN did not document how patient tolerated the wound care. Patient 8: On the SN assessment 11/14/25 there is documentation of wound care performed, the SN did not document how the patient tolerated the wound care.

Upon patient record review, 3 of 14 (Patient #1,3,8) 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 1: On the initial RN assessment there is documentation, UTA, UTA is not an approved abbreviation. On the RN assessment 11/19/25 the RN documented "wound care rendered as ordered" RN did not document the details of wound care performed. Patient 3: On the RN initial comprehensive assessment 6/18/25 the RN documented, "Pt. is able to ambulate with FWW". FWW is not an approved abbreviation. On the SN assessment dated 9/18/25 there is documentation, "On arrival patient SLUP", SLUP is not an approved abbreviation. Patient 8: On the SN assessment 11/14/25 there is documentation of wound care performed, the SN did not document the details of wound care performed.

Upon personnel record review,1 of 12 (Personnel #12 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 12: There is no evidence the hospice has obtained a criminal background check for this contracted employee.

Upon patient record review, 2 of 2 (Patient #1, 2) 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 Patient 1, 2: The patient's oxygen does not appear on the medication list. (corrected onsite)

Upon patient record review, 2 of 2 (Patient #1, 2) 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, 2: The patient utilizes a bed, over the bed table, wheelchair, oxygen, nebulizer, and suction machine for management of the terminal illness; however, this DME does not appear on the plan of care. (corrected onsite)

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. The agency did not have possession of the patient records from the previous owner. The agency stated that the original owner indicated that there were no admissions after the initial survey 3 years ago. The current owner took possession of the agency in September 2023. The agency has had only 2 admissions in the past 3 years and they were admitted on 6/14/24 and 6/16/24. Date of survey was 6/25/24.

Condition of Participation: Clinical Records.

Upon patient client record review, 1 of 2 (Patient #1) 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 1: On 06.18.2024 the patient had both a comprehensive psychosocial and spiritual assessment; at the conclusion of these assessments, each discipline determined monthly visits would be made. Visit orders were entered, and the initial plan of care reflects this frequency. However, a manual treatment order entered reflects both that the monthly visits will be made and that psychosocial and spiritual care visits were offered and declined. The DPCS verified that this was a typographical error. (corrected onsite)

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. The agency does not know the location of the patient records from three years ago.

Upon observation, the present hospice owner obtained the business in September 2023, with CMS and NGS approval of the change received on 05.03.2024. However, the present owner did not obtain the previous patient records from the former owner. As a result, these records were not available for inspection during survey and there was no evidence that the records are retained for a minimum of 6 years from the most recent discharge or death of the patient.