Every finding on record at Angels Light Hospice

Upon patient record review, 2 of 11 (Patient #1, #2) 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. Patient #1: On 8/30/2021 the medication profile included Tramadol 50 mg 1 as needed for pain. There was no specific frequency for Tramadol listed on the medication profile. Patient #2: On 9/18/2021 the medication profile included Zofran 4mg as needed for N/V. There was no specific frequency for Zofran on the medication profile.

Upon patient record review, 5 of 11 (Patient #1, #4, #5, #7, #11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #1, #4, #5, #7, #11: There was no evidence in the medical record of an initial bereavement assessment completed.

Upon patient record review, 2 of 11 (Patient #1, #2) 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 #1: The physician order on 8/30/2021 included Tramadol 50 mg 1 as needed for pain. There was no specific frequency for Tramadol in the physician order. Patient #2: The physician order on 9/18/2021 included Zofran 4mg as needed for N/V. There was no specific frequency for Zofran in the physician order.

Upon patient record review, 2 of 11 (Patient #1, #6) 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 physician order from admission and throughout care states "MSW evaluation starting 8/30/2021". The MSW evaluation visit was completed on 9/1/2021. There was also an MSW visit on 10/4/2021 and there was no order for this MSW visit. Patient #6: Upon admission on 10/1/2021, the physician order included Nursing evaluation only for episode 10/1/2021 to 12/29/2021. However, there was an SC visit made on 10/3/2021 and an MSW visit made on 10/2/2021. There was no evidence of a physician order for the SC or the MSW visits that were completed.

Upon patient record review, 1 of 1 applicable patient records (Patient #9) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #9: There was no evidence in the patient record of a bereavement plan of care.

Upon patient record review, 1 of 11 (Patient #4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4: The patient was admitted on 9/28/2021 in benefit period #1. The benefit period dates on the certification were incorrect and listed as BP #1: 9/28/2021 to 11/26/2021.

Upon patient client record review, 5 of 11 (Patient #1, #2, #3, #7, #11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated. Patient #1: The nurse visit notes dated 9/1/2021, 9/9/2021, and 9/18/2021 were signed by the nurse with no date indicating the date signed. Patient #2: The MSW visit note dated 9/22/2021 was signed by the MSW with no date indicating the date signed. Also, the SC visit note dated 9/21/2021 was signed by the SC with no date indicating the date signed. Patient#3: The nurse visit note dated 10/17/2021 was signed by the nurse with no date indicating the date signed. Patient #7: The nurse visit notes dated 10/11/2021 and 10/18/2021 were signed by the nurse with no date indicating the date signed. Patient #11: The nurse visit note dated 6/12/2021 was signed by the nurse with no date indicating the date signed.

Upon patient record review, 1 of 11 (Patient #11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #11: There was no evidence in the medical record that the written policies and procedures for managing controlled drugs was provided and discussed.