Every finding on record at Atrium Hospice LLC

Upon patient record review, 11 of 14 (Patient #1, 2, 3, 4, 5, 8, 9, 10, 11, 13, 14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 1, 2, 3, 4, 5, 8, 9, 10, 11, 13, 14. Neither box for "I do not wish to choose..." or "My choice for my attending physician is..." is checked. Medical Director's name is typed in.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and 8related conditions, including medications and treatments. Patient #3: Patient admitted 1/20/24 with Foley Catheter in place, with initial physician order for Foley catheter to gravity. Change Foley catheter monthly and as needed (not specific to circumstance of change. No size/balloon specified). Initial order for Peg tube site care: cleanse with normal saline. Pat dry. Cover with split gauze dressing. may secure with tape. Change 2-3 x a week and as needed. (circumstances not specified). Orders clarified/corrected during survey.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: SOC 1/5/24. It is documented by RN and SC that patient declined SC services. However the IDG POC has frequency as 1/month and 1 prn and has not been updated to reflect patient choice.

Upon client record review, 2 of 14 (Patient #3, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 1/20/24 MD order forwound care to right inner thigh wound: Clean with normal saline or soap and water. Pat dry. Cover with foam dressing. Change 2-3x a week and as needed if loose, wet or soiled. May discontinue when healed. However, 1/30/24 note by SN documented cleaned thigh wound with NS and applied Xeroform and Mepilex. 2/2/24 SN note documented Wound care to right thigh cleansing the area with NS and applying MediHoney over the wound, followed by a Xeroform dressing ...covered with bordered foam tape so did not follow plan of care. Patient #10: 9/10/23 MD order for Vol 2x/month. There were (3) visits Sept (11, 18, 20th) and Oct. (2, 16, 28th)

Upon patient record review 2 of 14 (Patient #2, 10) 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 #2: Admitted 1/20/24 and on 1/26/24 (Friday) there is documented communication note that HA unable to make visit r/t emergency. Son was informed. Documentation not clear if replacement was offered/declined. According to Policy 4-101.1 Missed Visits, the agency should have offered replacement. Patient #10: Admitted 7/21/23. 2/20/24 (Tues) HA out sick. Not clear if offered/declined replacement. According to Policy 4-101.1 Missed Visits, the agency should have offered replacement.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: SOC 7/21/23 in Benefit Period #4. Patient's hospice diagnosis identified as Senile Degeneration of Brain (G31.1) in Initial and subsequent IDG POCs and throughout the medical record. However, in CTIs for Benefit Period #4 (initial) and #5 (recertification), physician documented Parkinson's Disease (G20) as primary dx and also identified Parkinson's as admitting diagnosis in physician narrative and Face to Face documentation. Parkinson's is not listed in secondary diagnoses or co-morbidities, although during interview, staff report patient has history of Parkinson's.

Upon patient client record review, 11 of 14 (Patient #1, 2, 3, 4, 5, 8, 9, 10, 11,13, 14 ) • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients 1, 2, 3, 4, 5, 8, 9, 10, 11, 13, 14. Neither box for "I do not wish to choose..." or "My choice for my attending physician is..." is checked. Medical Director's name is typed in.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #8: SOC 9/26/23. Patient has GT requiring site care, left arm wounds and sacral and rt buttock wounds. She also has fungal rash. At start of survey there were multiple treatment orders that had been changed but not discontinued, risking misinterpretation/confusion for current treatment. (Example 11/01/23 order for skin tears left arm and 2/24/24 wound order, but the 11/1/23 order had not been discontinued). RN reviewed and updated orders to clarify current treatment. The patient is SNF resident and accountability for wound care was not specified. Education provided and but this was also updated during survey.