Every finding on record at Authentic Hospice Care, Inc.

Upon patient record review, 2 of 6 (Patient #1,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,3: No evidence for SC order for evaluation, RN initial assessment documented SC declined. SC made initial assessment.

Upon patient record review, 2 of 6 (Patient #1,3) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #1,3: Decline MSW services. RN initial assessment documents patients would like assistance with funeral home planning. No evidence of care plan identifying plan to assist families with funeral home planning.

Upon patient record review, 3 of 6 (Patient #1,2,3) 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 #1,2,3: No evidence of clinical information supporting admission to hospice on the CTI, only the diagnosis and attestation was documented.

Upon patient record review, 1 of 6 (Patient #1) 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: No evidence documentation of initial RN narrative states patient is alert and oriented x3. Patient terminal diagnosis is Alzheimer disease and Neuro section documented confused. Documentation throughout chart patient is alert and orient x1 in other areas of the chart.

Upon patient record review 1 of 5 (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4: The record indicated that the spiritual care counselor conducted a visit/assessment. The assessment did not include evidence of a date that the visit was conducted. In addition, the document was not signed or dated by the spiritual care counselor.

Upon patient record review, 1 of 5 records (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: The record indicated that the spiritual care counselor conducted a visit. There was not evidence that a visit frequency for the spiritual care counselor was a part of the plan of care.