Every finding on record at 1st Care Hospice, Inc.

Upon patient record review 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Pt # 6 - Pt was admitted 7/13/23. No evidence of a psychosocial assessment completed.

Upon patient record review, 1 of 14 (Patient #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 Pt #3- on home visit identified med discrepancy with meds in bubble wrap in home and the medication profile. Baclofen -on med profile - said 10 mg tab 1 time daily yet in bubble pack from pharmacy was 20 mg tabs 1.5 tab 3 times/day. Doxazosin on med profile/order said 4 mg 1 time/daily and in the bubble pack was 1 tab 2 times/day. Linzess on med profile said 72 mcg daily and in bubble pack was 145 mcg tab daily. Pantoprazole was 20 mg on med profile and 40 mg. in bubble wrap pack. Acetaminophen 325 mg was not on medication profile yet in bubble wrap pack.

Upon patient record review, 2 of 14 (Patient #1, 4) 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. Pt #1- Admitted to hospice 4/24/23. Bereavement risk assessment not completed until 5/15/23. Pt #4 - Admitted 7/12/23. No bereavement risk assessment completed within 5 days.

Upon patient record review, 1 of 14 (Patient #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. Pt #3 - on home visit noted patient was taking acetaminophen 325 mg 1 qd. No evidence this was on the plan of care.

Upon patient record review 1 of 14 (Patient #5) 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 Pt #5- Pt's care plan includes: change linen and shampoo. On aide visit notes of 7/12, 7/14, and 8/1 - no documentation to reflect that shampoo nor change linens were addressed. On visits of 7/24 and 7/28, no shampoo was addressed.

Upon patient record review, 1 of 14 (Patient #1) 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. Pt #1 - Pt's second benefit period started 7/23/23. No CTI noted in record(8/2/23). Corrected on site.