Every finding on record at About You Palliative Care & Hospice LLC

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. The agency did not ensure the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/24/2024 with diagnosis of heart disease. The plan of care dated 02/24/2024 assigned the Hospice Aide the task of bed bath every visit. The Hospice Aide documented on the aide visit note dated 03/06/2024 a shower was provided. The Hospice Aide did not provide tasks as assigned on the plan of care. During a joint record review and interview on 04/30/2025, the Licensed Practical Nurse/Intake Coordinator confirmed that the Hospice Aide did not follow the aide plan of care with respect to tasks assigned.

Upon patient record review 1 of 5 (Patient #5) 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. Patient #5: No evidence of a comprehensive psychosocial assessment being completed.

Upon client record review, 3 of 5 (Patient #1, #2, #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SC visits on 11/11/21, 12/7/21, 1/4/22, 2/1/22 and 2/7/22. No evidence of an order for these visits. Order on 2/16/22 for SC 1 time a month. SC visits completed on 3/1/22 and 3/28/22. SW ordered 1 time a month on the initial plan of care. SW visits completed on 1/5/22 and 1/31/22. Patient #2: SW ordered 1 time a month on the initial plan of care. SW visits completed on 1/5/22 and 1/31/22. Patient #3: SW ordered 1 time a month on the initial plan of care. SW visits completed on 1/5/22, 1/31/22, 2/7/22 and 2/25/22.

Upon patient client record review, 4 of 5 (Patient #1, #2, #3, #5) 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: CTI for benefit period 1 only contained the SOC date of 10/13/2021. Benefit period date entry was incomplete. Patient #2: CTI for benefit period 1 only contained the SOC date of 10/13/2021. Benefit period date entry was incomplete. On the consent form, the section where patient can elect to receive or not receive a copy of the Patient Notification of Noncovered items was left blank. It is unclear if the patient wanted to receive this information. Patient #3: CTI for benefit period 1 only contained the SOC date of 10/13/2021. Benefit period date entry was incomplete. On the consent form, the section where patient can elect to receive or not receive a copy of the Patient Notification of Noncovered items was left blank. It is unclear if the patient wanted to receive this information. Patient #5: CTI for benefit period 1 only contained the SOC date of 11/1/2021. Benefit period date entry was incomplete. On the consent form, the section where patient can elect to receive or not receive a copy of the Patient Notification of Noncovered items was left blank. It is unclear if the patient wanted to receive this information.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 5 (Patient #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #5: The patient had a start of care date of 10/22/2021, however, there was no indication a psychosocial assessment had been conducted until 10/28/2021 (Day 6).

Upon patient record review, 5 of 5 (Patients #1, #2, #3, #4 and #5) 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. Patient #1: On a Nursing visit conducted on 11/24/2921, the Nurse documented the patient had starting using Diclofenac patches. Diclofenac patches was not listed to the medication list. Patient #2: On a Nursing visit conducted on 11/10/2021, the Nurse documented the use of laxatives Milk of Magnesia and Senna S. Neither medication was added to the medication list. Patient #3: On a Nursing visit conducted on 10/27/2021, the Nurse documented the use of Insulin. Insulin had not been added to the medication list. Patient #4: On the Nursing Comprehensive Assessment, the Nurse documented the use of internal Morphine pump. Morphine had not been added to the medication list. Patient #5: On the Nursing visit conducted on 11/10/2021, the Nurse documented the use of intrathecal pain pump. There was no medication for the pain pump listed on the medication list.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 (Personnel #2 ) did not have evidence in the personnel file that a competency assessment was performed.. Personnel #2: Although the Aide had been conducting visits, there was no documentation to indicate a competency assessment had been conducted prior to the visits.