Every finding on record at American All Care Services, LLC

Upon patient record review 2 of 14 (Patient #1, 4) 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 1: There was no evidence that the comprehensive initial assessment identified either the psychosocial or spiritual needs of the patient/family. Patient 4: There was no evidence that the comprehensive initial assessment identified the psychosocial needs of the patient/family.

Upon patient record review, 1 of 14 (Patient #1) 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: The patient had a nebulized medication listed on the medication list (DuoNebs); however, there was no nebulizer included on the plan of care. (corrected onsite)

Upon patient record review 2 of 14 (Patient #1,2) 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 Patient1: Aide visits were initially ordered for 3 x weekly, then reduced to 2 x weekly on 07.15.2023. On 07.31.2023, Aide visits were ordered to be discontinued altogether, citing the family's preference to provide this care themselves. However, from the patient's admission on 07.07.2023 until Aide visits were discontinued on 07.31.2023, only two Aide visits were made - on 07.15.2023 and 07.21.2023. Though the DPCS was able to provide a verbal explanation that these visits were refused by the family on an ongoing basis, and this is why Aide services were ultimately discontinued, there was no evidence or documentation in the EMR related to the missed visits. Patient 2: Aide visits were ordered for 2 x weekly. However, during the week of 07.16.2023, only one Aide visit was made - on 07.19.2023; there was no evidence or documentation related to the missed visit.

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the discharge summary includes all required information. Patient 6: On discharge, responsibility for the patient's care was assumed by the ALF where the patient resides. However, there was no evidence the hospice communicated with the ALF prior to or at the time of discharge in providing the current plan of care, physician's orders, etc. to ensure safe & effective continuity of care for the patient.