Every finding on record at Altus Hospice, Inc.

Upon patient record review, 2 of 14 (Patients #1, #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 Patient #1: This Patient has Crestor 10 mg 1 tab @ bedtime in his home medication stock. The Hospice Medication Profile indicated Crestor 20 mg 1 tab @ bedtime. Patient#3: Polyethylene Glycol order with no diluent indicated on medication profile.

Upon patient record review, 6 of 14 (Patients #5, #6, #9, #11, #12, #13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #5, #6, #11: The initial POC indicated Chaplain visit frequency of, Evaluation and PRN visits. This frequency did not include a baseline visit frequency for the Chaplain. Patient #9: The initial POC indicated Chaplain and MSW visit frequency of, Evaluation and PRN visits. This frequency did not include a baseline visit frequency for the Chaplain and MSW. Patient #12: Chaplain visit frequency of, "er.fox" for PRN visits f This frequency did not include a baseline or clear PRN amounts of visit frequency for the Chaplain. Patient #13: The initial POC did not include frequencies for Nursing, Social Worker or Chaplain in space provided on the form.

Upon patient record review, 2 of 14 (Patients #1, #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. Patient #1: This Patient has Crestor 10 mg 1 tab @ bedtime in his home medication stock. The Hospice Plan of Care indicated Crestor 20 mg 1 tab @ bedtime. Patient#3: Polyethylene Glycol order with no diluent indicated on Plan of Care.

Upon patient record review, 3 of 14 (Patients #12, #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #12, #13, #14: Did not have Bereavement Plan of Care in patient record. Agency has record that cards and mailing were sent per Policy and Procedures.

Upon patient record review 1 of 14 (Patient #3) 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 Patient #3: The POC listed Aide visit frequency of, 1 X per week. There were no visits made by the Aide during 1st Benefit Week. Additionally, the Aide routinely performs the tasks that are not on Aide Care Plan (10/8/23). Such as, vital Signs, nail file, soak feet and straighten room.

Upon patient client record review, 4 of 14 (Patients #5,7,9,10) 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 #5, #7, #9, 10: The Discharge Summary was not signed/dated by clinician.