Every finding on record at Amazing Hands Hospice LLC

Upon patient record review 2 of 14 (Patient #2, #12) 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 #2 There was no evidence of an MSW assessment completed within 5 days. Patient #12 There was no evidence of an MSW assessment completed within 5 days of admission.

Upon patient record review, 1 of 14 (Patient#14) 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: • Drug side effects • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring patient #14: Per MD certification dated 4-28-23 the patient was using Oxygen at 3l/NC. Oxygen was not on the medication profile.

Upon patient record review, 1 of 14 (Patient #12) 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 #12: There was no evidence of a bereavement assessment completed within 5 days of admission.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar day. Patient #13; the IDG plans of care were completed on 09/15, 10/04 and 10/30 indicating greater than 15 calendar days.

Upon patient record review, 3 of 14 (Patient #1, #3, #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: Aide frequency 2 x week remained on IDG/POCs after aide was discontinued on 2-8-24. Patient #3: Aide frequency of 2 x week remained on IDG/POCs after aide was discontinued on 02-29-24. Patient #7: Aide frequency of 2 x week remained on IDG/POCs after aide was discontinued on 03-03-24.

Upon client record review, 3 of 14 (Patient #3, 9, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 Per POC the MSW visit frequency was 1 x mo. There was no MSW visit in the month of March and no missed visit note evidenced. Patient #9 Per the 2-8-24 and 2-22-24 POC, SW frequency was 1xmo. There was no visit in the month of February and no missed visit note evidenced. Patient #13 On 10-12-23, MSW documented "Patient agreed with SW for another visit next week to complete the environmental and psychosocial assessment". There was no visit until the next month.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #14: Per the aide plan of care dated 4-29-23, the RN ordered tasks of 1) partial bath and shower, 2)complete shower and 3)bed bath. In addition, the RN ordered assist in ambulation and and assist with bedside commode and the patient was non ambulatory.

Upon patient record review, 4 of 14 (Patient #3, #5, #7, #9) 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. Patient #3, #5: There was no evidence of a recertification for period beginning 02-29-24. However, there was a F2F documented. Patient #7: There was no evidence of a recertification for period beginning 03-03-24. However, there was a F2F documented. Patient #9: There was no evidence of a recertification for period beginning 01-23-24.

Upon patient record review, 14 of 14 (Patient #1, #2, #3, #4, #5. #6, #7, #8, #9,#10, #11, #12, #13, #14 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient 1-14: All Patients reviewed did not have evidence that the IDG determined the ability of the patient or family to safely self-administer medications.