Every finding on record at American Cm Hospice Inc.

Upon patient record review, 2 of 13 (Patients #1 and #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: Patient #1 and 3 Had an order for oxygen prn. Oxygen is not listed on medication profile.

Upon patient record review, 3 of 13 (Patients #1, #2 and #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 equipment and supply needs. Patient #1: This patient had a bed, over-bed table, oxygen concentrator and nebulizer machine. These were not included on the Plan of Care. Patient #2: The DME on POC listed hospital bed and raised toilet seat. The patient did not have these items in her ALF room. Patient #3: This patient had an oxygen concentrator and a fall mat. These were not included on the Plan of Care.

Upon client record review, 5 of 13 (Patients #1, #2, #3, #4 and #7) 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 days. Patients #1, #2, #3, #4: The agency IDG meeting agenda dated 12/21/22 listed patient(s) name on spreadsheet to discuss. However, the Patient electronic medical record did not reflect the IDG meeting occurred on 12/21/22 to meet 15 day requirement to review/revise. IDG meeting occurred on 12/6/22 and 1/4/23. Patient #7: The agency IDG meeting agenda dated 12/28/22 listed patient name on spreadsheet to discuss. However, the Patient electronic medical record did not reflect the IDG meeting occurred on 12/28/22 to meet 15 day requirement to review/revise. IDG meetings occurred on 12/14/22 and 1/11/23.

Upon client record review, 6 of 13 (Patients #1, #2, #3, #4, #7 and #10) 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 listed Skilled Nursing visit frequency of 1 X per week and the MSW visit frequency of 1X per month. For Benefit Week 10/23/22 there were two SN visits on 10/25/22 and 10/27/22. For Benefit Months November there were two MSW visits and December there were three MSW visits made. Patient #2: The POC listed MSW visit frequency of 1 X per month, the Chaplain visit frequency of 3X's per month and Volunteer visit frequency of 2 X's per month. MSW visited 2X's in November (11/8 and 11/22), the Chaplain visited 4X's (8/8, 8/15, 8/23 and 8/29) and Volunteer had no visits made for July or August. Patient #3: The POC listed MSW visit frequency of, 1 X per month and the Chaplain visit frequency of 2X's per month. The MSW visited 2X's in November (11/2 and 11/28), the Chaplain visited 1X in October (10/17/22). Patient #4: The POC listed Skilled Nursing visit frequency of, 1 X per week. For Benefit Week 11/13/22 there was two visits on 11/16/22 and 11/18/22. The visit frequency was not met. Patient #7: The POC listed MSW visit frequency of, 1 X per month and the Chaplain visit frequency of 2X's per month. For the month's of November the MSW visited two times (11/22/22 and 11/29/22) and the Chaplain visited one time (11/29/22). Patient #10: The POC listed MSW visit frequency of, 1 X per month and the Chaplain visit frequency of 2X's per month. For the month of November, the MSW visited two times (11/18/22 and 11/23/22). For month of September, the Chaplain visited one time (9/27/22).

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: Personnel #9 Did not have observational evaluation (only verbal) for the following competencies: · Normal range of motion and positioning · Toileting and elimination

Upon patient record review 6 of 13 (Patients #2, #4, #5, #7, #9 and #11) 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 #2: The POC listed aide visit frequency of 2 X's per week. For Benefit Weeks (BW) 10/16/22 three visits were made (10/17, 10/18 and 10/19), BW 11/6/22 three visits were made (11/7, 11/8 and 11/9) and BW 12/4/22 one visit was made (12/7/22). Patient #4: The POC listed aide visit frequency of 2 X's per week. For Benefit Week 11/20/22 one visit was made on 11/21/22. Patient #5: The POC listed aide visit frequency of 2 X's per week. For Benefit Week 12/11/22 one visit was made on 12/14/22. Patient #7: The POC listed aide visit frequency of 2 X's per week. For Benefit Week 12/4/22 one visit was made on 12/6/22. Patient #9: The POC listed aide visit frequency of 5 X's per week. For Benefit Week 12/4/22 three visits were made on 12/5/22, 12/7/22 and 12/8/22. Patient #11: The POC listed aide visit frequency of 2 X's per week. For Benefit Week 11/13/22 one visit was made on 11/17/22.

Upon patient client record review, 1 of 13 (Patient #4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #4: The Beneficiary elected to receive the Patient Notification of Hospice Non Covered Items on SOC date 9-13-22. There was no evidence that the Hospice furnished this addendum within 5 days as requested at SOC.

Upon client record review, 1 of 13 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: Transferred to another hospice, the hospice did not provide all documents required for transfer, which were: ŸŸŸ• Copy of signed consents for care • Copy of the certification of terminal illness