Every finding on record at All Day Hospice Care, Inc

Upon patient record review 3 of 14 (Patient #2, #5 and #6) 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 #2-The Aide POC had task "Vital Signs Each Visit." There were no VS documented on any of the aide visits in the patient record. #5-The Aide POC had task "Vital Signs Each Visit." There were no VS documented on any of the aide visits in the patient record. #6-The Aide POC had task "Vital Signs Each Visit." There were no VS documented on any of the aide visits in the patient record.

Upon patient record review, 2 of 5 (Patient #1 and #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: This patient had a shower chair. This was not included on the Plan of Care. Patient #2: This patient had a bed, side rails, bed side commode and over the bed table. These were not included on the Plan of Care.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 The POC dated 7/31/21 listed MSW visit 1x monthly. There were no MSW visits documented for the month of July. The first MSW visit was 8/1/21

Upon patient record review 1 of 2 applicable (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care. Patient #3- The POC dated 07/31/21 listed an Aide visit frequency of 2 x week. There were no Aide visits documented week 1.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence that the medical director or physician designee provided a complete written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #1 The initial (completed on 7/7/21) Certificate of Terminal Illness document did not include the benefit period dates. Patient #2 The initial (completed on 8/7/21) Certificate of Terminal Illness document did not include the benefit period dates. Patient #3 The initial (completed on 7/31/21) Certificate of Terminal Illness document did not include the benefit period. Patient #4 The initial (completed on 7/3/21) Certificate of Terminal Illness document did not include the benefit period dates. Patient #5 The initial (completed on 6/26/21) Certificate of Terminal Illness document did not include the benefit period dates.

Upon patient record review, 3 of 3 applicable (Patient #1, #2, #3) 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 a complete written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1 The recertification (completed on 10/11/21) Certificate of Terminal Illness document did not include the benefit period dates. Patient #2 The recertification (completed on 11/1/21) Certificate of Terminal Illness document did not include the benefit period dates. Patient #3 The recertification (completed on 10/25/21) of the Certificate of Terminal Illness document did not include the benefit period.