Every finding on record at Astrea Hospice, Inc.

Upon patient record review, 2 of 14 (Patients #1 and #8) 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: The patient had Oxygen Concentrator in the home. There is no oxygen listed on the Medication Profile/POC. Corrected on Site. Patient #8: The record reflected this patent had Oxygen Concentrator in the home. There is no oxygen listed on the Medication Profile/POC. Corrected on Site

Upon patient record review, 6 of 14 (Patients #1,2,7,8,9,10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patients #1,2,7,9,10: The POC listed MSW visit frequency as needed and recert. The PRN frequency did not include a number of PRN visits ordered for the MSW. Patient #8: The POC listed SC and MSW visit frequency as needed and recert. These PRN frequencies did not include a number of PRN visits ordered for the SC or MSW.

Upon patient record review, 2 of 14 (Patients #1 and #8) 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 patient had Oxygen Concentrator in the home. There was no oxygen order. Corrected on Site. Patient #8: The record reflected this patent had Oxygen Concentrator in the home. There was no oxygen order. Corrected on Site.

Upon patient record review, 3 of 14 (Patients #2, #3, #8) 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 #2:This patient had a bedside table. This item was not included on the Plan of Care. Patient #3: This patient had a bedside table. This item was not included on the Plan of Care. Patient #8: The record reflected that this patient had a oxygen concentrator. This item was not included on the Plan of Care.

Upon patient record review 3 of 14 (Patients #1, 7 and 8) 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 #1: The POC listed Aide visit frequency of, 2 X's per week (9/15/23). For the first Benefit Week, there were no visits made by the Aide. Patient #7: The POC listed Aide visit frequency of, 2 X's per week (4/10/24). There are no Aide visits to date. Patient #8: The POC listed Aide visit frequency of, 2 X's per week (12/7/23). For the first Benefit Week, there was only 1 visit on 112/8/23 only and no visit the 2nd benefit week.

Upon patient record review, 12 of 14 (Patients #1,2,3,4,5,7,8,9,10,11,12,13,14) 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 • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients #1,2,3,4,5,7,8,9,1011,12,13,14: The CTI included hospice primary diagnosis. The CTI did not include any related or unrelated diagnosis in space provided on form.

Upon patient client record review, 2 of 14 (Patient #1 and #6) 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: The Initial POC did not have correct benefit period for SOC of 9/15/23. The POC indicated Benefit Period #1 at SOC for 9/15/23. The patient was on hospice service prior from 6/21/23 to 9/10/23 (Benefit #1). Patient Initial POC should have reflected the current Benefit Period #2, not Benefit #1. Patient #6: Listed the "Aide Visit Frequency: per week" on 3/25/24. This frequency did not indicate a specific number of times per week. The patient is not receiving Aide services and per agency this was a typo. Corrected on Site.

Observed in Record Review. In 1 of 2 patient records reviewed, During RR#1 it was noted on the POC, PRN frequencies for the MSW and Chaplain. The frequencies lacked the reason and number of proposed PRN visits needed in the certification period. This was discussed with the organization leaders.

Observed in Record Review. During HV#1 record review it was noted oxygen therapy at 2-4 L/min PRN SOB on the POC. The oxygen equipment is not listed under DME/supplies on the POC as well as other supplies provided for the patient care. This was discussed with the organization leaders.