Every finding on record at Az Best Hospice Care Inc.

Upon patient record review, 1 of 5 (Patient # 4) did not have evidence that the patient chooses a health care provider, including an attending physician. The medical record contained an election of benefits with the section pertaining to election of attending physician left blank.

Upon client record review, 3 of 3 applicable records (Patients #1,#2,#3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patients 1, 2, and 3: Patients were admitted 12-17-21. There was evidence of an IDT meeting 12-31-21 but no evidence that the plans of care were reviewed and/or updated.

Upon observation at home visit, 1 of 3 (Patient #2) did not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During home visit, the clinician was observed placing vital sign equipment back onto barrier pad next to dirty equipment and in the same spot it resided when dirty. There was no designated clean and dirty areas on the barrier pad used.

Upon patient record review, 1 of 5 records (Patient #5) 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. • Ensuring that bereavement services reflect the needs of the bereaved Patient 5: The medical record contained documentation by the bereavement coordinator stating mailings and phone calls would persist in accordance with bereavement program. There was no evidence of mailings or phone calls since initial letter sent following patient death. Patient died in March 2021.

Upon patient record review 1 of 1 applicable record (Patient #4) 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 4: The medical record contained aide documentation identifying which tasks were assigned to complete but the aide did not identify which tasks were completed during the visits. The form provided check boxes to allow documentation for completed and refused tasks as well as an area for free text but areas for identification and description of care provided were left empty.

Upon patient client record review, 2 of 5 records (Patients #4,#5) did not have evidence that each patient record contains signed election statement in accordance with 418.24. Patient 4: The medical record contained an election of benefits with sections pertaining to election of attending physician and election of notice of non-covered items empty. The election of benefits was also unsigned by the beneficiary or representative. Patient 5: The signed election of benefits form did not contain notification of the patient or representative ability to receive notice of non-covered items.

Upon patient client record review, 3 of 5 records (Patients #1, #2, #3) 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. Patient 1: The medical record contained a nursing comprehensive assessment upon admission that identified the patient did not have skin breakdown but also stated that wound care was completed. Leadership confirmed the patient did not have a wound and the documentation system template was autogenerating the specific description of wound care if nurse selected yes to wound care received. The template also falsely generated that male patient was in menopause and the nurse did not edit the issue out of final document. Patient 2: The medical record contained a nursing comprehensive assessment upon admission that identified the patient did not have skin breakdown but also stated that wound care was completed. Leadership confirmed the patient did not have a wound and the documentation system template was autogenerating the specific description of wound care if nurse selected yes to wound care received. Patient 3: The medical record contained a nursing comprehensive assessment upon admission that identified the patient did not have skin breakdown but also stated that wound care was completed. Leadership confirmed the patient did not have a wound and the documentation system template was autogenerating the specific description of wound care if nurse selected yes to wound care received. The template also falsely generated that male patient was in menopause and the nurse did not edit the issue out of final document.