Every finding on record at Amity Hospice Care LLC

Upon patient record review, 2 of 5 (Patient #2, 4) 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 medications and treatments. Patient #2: 5/3/23 MD Order May start with Foley Catheter 18 fr. 10 ml to keep patient dry and clean/change every month as needed. May flush Foley catheter 30ml of normal saline every SN visit / as needed to prevent occlusion. Order does not include as needed reason for changing catheter. Patient #4: 3/12/23 MD orders: May flush with 5 ml normal saline every SN visit to prevent clogging. Order does not specify which nephrostomy tube or if order pertains to both. Change nephrostomy bag every month. It does not specify which tube or if both.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: SN Visit 3/15/23: "SN documented nephrostomy tube remains intact... flushed Foley catheter with NS at the time of visit." Upon interview questioned RN/DPCS regarding Foley notation. He reports that patient had Foley briefly upon admission, but it was removed, as it was not draining. Foley catheter was not included in initial POC and neither was removal. SN visit notes 3/22, 4/12, 5/10/23 state Nephrostomy dressing changed. There is no order for nephrostomy dressing change.

Upon patient client record review, 4 of 5 (Patient #1, 2, 3, 4) 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 #1: 7/31/23 IDG meeting note entry under psychosocial .. "4/21/23 was last visit" but there is no MSW note for visit. The last documented MSW visit note is 1/29/23. Patient #2: Initial IDG 2/24/23 inadvertently documented under discussion/other "CHHA 3xwk for ADL assistance." Frequency section of meeting note says "HA 4/wk". Visits are provided 4x/wk in accordance with order. Also for SN visits 6/23, 6/30, 7/10, 7/14/23, it was documented that "Wound care done. Tolerated well." The documentation is not specific to interventions performed to demonstrate compliance with orders/POC. Patient #3: For SN visit notes: 5/17, 6/28, 7/7/23, it was documented "Wound care done and tolerated well."The documentation is not specific to intervention performed to demonstrate compliance with orders/POC. Patient #4: SN Visit 3/15/23: "SN documented nephrostomy tube remains intact... flushed Foley catheter with NS at the time of visit." Documentation is not specific to if left or right or both nephrostomy tubes were flushed and amount and results.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient #4 admitted 3/12/23 and revoked Hospice Medical Benefit 5/16/23. He chose aggressive care in a non-contracted hospital. The discharge summary included a summary of the circumstances surrounding revocation, but it was not inclusive of a summary of the patient's stay, including treatments, symptoms and pain management. It was not specific to current physician orders or if education was provided.