Every finding on record at Anthem Hospice Care, Inc

Upon patient record review, 1 of 10 records reviewed (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3: The record indicated there was a place for the patient to choose an attending physician for hospice. There was no evidence in the record the patient chose an attending physician for hospice evidenced by the form was blank.

Upon patient record review 1 of 10 (Patient #1) 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: The record indicated the start of care was on 10/20/23. There was no evidence of the comprehensive assessment for the spiritual assessment and psychosocial assessment being completed.

Upon patient record review, 10 of 10 charts reviewed (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1-#7: The record indicated medications on the medication administration record. The chart did not have evidence of that the effectiveness of drug therapy, actual or potential drug interactions, duplicate drug therapy and or drug therapy currently associated with laboratory monitory was being reviewed. Patient #8-#10: The record indicated medications on the medication administration record. The chart did not have evidence duplicate drug therapy and or drug therapy currently associated with laboratory monitory was being reviewed. Patient #1: The record indicated on the MAR Cromolyn Sodium 4% Ophthalmic Solution 2 drops ophthalmic 4 times daily as needed for eye allergies. There was no evidence as to which eye or eye(s) to put the drops in. COS.

Upon patient record review, 2 of 10 records reviewed (Patient #2, #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The record indicated the patient tested positive for COVID on 7/31/22 with a plan of care for preventing COVID. There was no evidence of an individualized written plan of care that was necessary for the palliation and management of the COVID. Patient #4: The record indicated at the start of care on 12/27/22 the nursing assessment for imminent death included decreased level of consciousness, decreased food and fluid intake and decreased/absence of bowel/bladder functioning. There was no evidence of an individualized written plan of care for the imminent death.

Upon patient record review, 2 of 10 medical records reviewed (Patient #1, #5) 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 MD order indicated Cromolyn Sodium 4% Ophthalmic Solution 2 drops ophthalmic 4 times daily as needed for eye allergies. There was no evidence in the order as to which eye or eye(s) to put the drops in. COS. Patient #5: The record indicated an order for a 18 French Foley with a 10cc balloon. There was no evidence of what solution to use to inflate the balloon. COS.

Upon client record review, 1 of 10 records reviewed (Patient #1) 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 record indicated an LVN visit 2 X W effective on 5/31/24. There was no evidence of a second nurse visit between 06/01/24 and 06/08/24.

Upon patient record review, 2 of 10 records reviewed (Patient #1, #2) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #1: The record indicated on 6/15/24 the patient requested a visit for high fever and a visit was made. There was no evidence that the IDG documented the sharing of this information between all disciplines providing care. Patient #2: The record indicated on 7/31/22 the patient tested positive for COVID. There was no evidence that the IDG documented the sharing of this information between all disciplines providing care.

Upon patient record review, 1 of 10 (Patient #4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #4: The record indicated the 4th benefit CTI for 12/27/22 to 2/24/23 required a physician narrative immediately above the physician's signature. There was no evidence on this CTI of the narrative as it had written in the space "CTI in Chart" and no narrative was written in this space.