Every finding on record at Americare Hospice

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11, Orders for LVN 1x/week, RN every 14 days, RN made a visit on 5/25/22, 5/29/22, 5/31/22, no LVN visit completed. Patient #12, Orders state MSW declined, SC declined. Both MSW and SC made initial evaluation without MD order. Assessment on 2/8/22, B/P diastolic 94, orders to notify MD if greater than 90, no documentation that MD was notified.

Upon patient record review 1 of 14 (Patient #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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #11, HHA visit completed on 5/30/23 without MD order for HHA visits.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #11, Another patient initials A.K. DOB 7/11/45, information was in chart, change of hospice provider and election of Medicare, consent for treatment.