Every finding on record at Always Accurate Home Healthcare and Hospice LLC

Upon patient record review, 5 of 14 (Patient #3,#6,#7,#9,#10) did not have evidence in the patient record that a review was completed of all prescription that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: Per plan of care dated 11/3/23, the patient "required PRN O2 at 2L per NC." There was no evidence of oxygen administration on the medication profile. Patient #6: Per LPN note dated 1/4/24, the patient was using oxygen "continuous at 2.5 LPM via NC." There was no evidence of oxygen administration on the medication profile. Patient #7: Per RN assessment on 05/08/23, the patient was continually using O2, 2-4 LPM via NC. There was no evidence of oxygen administration on the medication profile. Patient #9: Per plan of care dated 12/29/23, the patient was O2 dependent at "5L per NC." There was no evidence of oxygen administration on the medication profile. Patient #10: Per plan of care dated 12/15/23. the patient was using O2 at 2L per NC, but there was no evidence this was documented on the medication profile.

Upon patient record review, 1 of 14 (Patient #11) 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. Patient #11: There was no evidence of documentation of a bereavement assessment by the SW, Chaplain or RN in the patient record.

Upon client record review, 2 of 14 (Patient #3, #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The plan of care, dated 11/3/23 indicated SW visits were 1 x month. The SW documented routine visits for the patient on 11/6/23, 11/7/23 and 11/21/23. Patient #6: The plan of care dated 10/19/23 indicated SW visits were 1 x month. There was no evidence of documentation of a SW visit in the month of December 2023.

Upon patient record review, 2 of 14 (Patient #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13, #14: During the client bereavement record review, there was no evidence of documentation of the interventions listed and dated in the bereavement plan of care.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patient #11: The written instructions on the aide plan of care dated 11/28/23 indicated that the aide was to "perform wound care dressing change" at each visit. There was not evidence of the specific wound care to be performed by the aide in the aide care plan or IDT care plan.

Upon patient client record review, 2 of 14 (Patient #1,#11,) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: The Hospice Election statement dated 08/11/23 was signed by a family member without evidence of documentation that: 1) the patient was unable to sign and 2) why the patient was unable to sign. Patient #11: The Hospice Election statement dated 11/28/23 was signed by the POA without evidence of documentation that: 1) the patient was unable to sign and 2) why the patient was unable to sign.

Upon patient client record review, 1 of 14 (Patient #12) 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 #12: The RN documentation for 11/13/23 indicated an aide supervisory visit was completed. There was no evidence that an aide was assigned to the patient or that an aide visited until 12/7/23.