Every finding on record at Az Hospice Care Inc

Upon patient record review, 2 of 5 (Patient #2, 3) 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 #2- The medication profile included lidocaine cream to be applied topically. There was no site for application indicated. Patient #3- the medication profile included diclofenac 1% gel to be applied topically. There was no site for application indicated. The medication profile included oxygen 2-4L by nasal cannula as needed. No indication for how to determine which liter strength to be used.

Upon patient record review, 1 of 5 (Patient #5) 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 #5- The patient was assessed to be at a high risk for skin breakdown. The plan of care did not include goals and interventions related to risk for breakdown.

Upon patient record review, 2 of 5 (Patient #2, 3) 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 #2- The plan of care included lidocaine cream to be applied topically. There was no site for application indicated. Patient #3- The plan of care included diclofenac 1% gel to be applied topically. There was no site for application indicated. The plan of care included oxygen 2-4L by nasal cannula as needed. No indication for how to determine which liter strength to be used.

Upon patient record review, 1 of 5 (Patient #1) 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 #1- The medical record contained information that the patient had a geri chair and required incontinent supplies. The DME and supplies necessary for the patient's care were not included on the plan of care.

Upon patient record review, 1 of 13 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 3 of 13 records (Patient #6, #8, #12) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #6: The record indicated the election of benefit was dated 04/10/2022 however, the RN initial assessment did not occur until 04/18/2022. Patient #8: The record indicated the election of benefit was dated 03/30/2022 however, the RN initial assessment occurred on 03/29/2022. Patient #12: The record indicated the election of benefit was dated 06/11/2022 however, the RN initial assessment occurred on 06/09/2022.

Upon patient record review 9 of 13 records (Patient #2, #4, #5, #6, #7, #8, #10, #11, #13) 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 #2: The patient admitted 03/31/2022, however the record indicated social worker comprehensive was not completed until 04/07 and the spiritual care comprehensive was not completed until 05/04. Patient #4: The patient admitted 11/30/2021, the spiritual care comprehensive was not completed until 12/08/2021. Patient #5: The patient admitted 03/14/2022, the spiritual assessment on 03/21/2022. Patient #6: The patient admitted 04/10/2022, the psychosocial assessment was completed on 05/03/2022 and spiritual assessment on 06/17/2022. Patient #7: The patient admitted 06/16/2022, the psychosocial assessment was completed on 06/23/2022. Patient #8: The patient admitted 03/30/2022, the spiritual assessment was completed on 04/05/2022. Patient #10: The patient admitted 06/05/2022, the spiritual assessment was completed on 06/14/2022. Patient #11: The patient admitted 04/01/2022, the spiritual assessment was completed on 04/08/2022. Patient #13: The patient admitted 05/17/2022, the psychosocial assessment was completed on 05/24/2022 and spiritual assessment on 06/06/2022.

Upon patient record review 3 of 13 records (Patients #5, #9, #12) 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 #5: The patient admitted 03/14/2022, no evidence of psychosocial assessment after admission. Patient #9: There was no evidence that the comprehensive included assessment for spiritual needs. Patient #12: There was no evidence that the comprehensive included assessment for physical and spiritual needs.

Upon patient record review, 6 of 13 records (Patient #2, #3, #4, #10, #12, #13) 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 #2: Medication profile included miconazole powder 2% apply to affected areas twice daily as needed for excoriation however, there was not evidence of a specific location. In addition, medication profile included miralax 3350/17g oral daily did not contain evidence of directions for use. [corrected on site] Patient #3: The admission orders dated 05/03/2022 for oxygen 2-4L PRN for dyspnea and/or respiratory distress and nurse visit notes on 06/24, 06/21, and 06/14 indicated the patient was wearing oxygen however, there is not evidence of the oxygen on the medication profile. [corrected on site] Patient #4: The admission orders dated 11/30/2021 for oxygen 2-4L PRN for dyspnea and/or respiratory distress however, there is not evidence of the oxygen on the medication profile. [corrected on site] Patient #10: The admission orders dated 11/30/2021 for oxygen 2-4L PRN for dyspnea and/or respiratory distress however, there is not evidence of the oxygen on the medication profile. Patient #12: The medication profile indicated order 06/19/2022 for fluconazole 150 mg tablet, take 1 per for 3 days remained active. [corrected on site] Patient #13: The medication profile indicated an order for miralax 3350/17g oral daily did not contain evidence of directions for use. In addition, admission order indicated oxygen 2-4L PRN for dyspnea and/or respiratory distress however, there is not evidence of oxygen on medication profile.[corrected on site]

Upon patient record review, 13 of 13 records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #1-#13: No evidence that an initial bereavement assessment was completed upon admission by RN, SW, or SC.

Upon patient record review, 4 of 13 (Patients #1, #2, #3, #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1, 2, 3, 4: The record did not contain evidence of registered nurse visit since 06/21/2022, and no evidence of an updated comprehensive assessment since 06/21/2022.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 13 (Patients #3, #5, #6, #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: The nurse comprehensive assessment indicated the patient had a surgical wound however, there was no evidence of a wound assessment or measurements. Patient #5: The nurse comprehensive assessment on 03/14/22 and follow up nurse visit on 04/14/22 both indicated the patient had wounds however, there was no evidence of the wounds being fully assessed to include measurements. Patient #6: The nurse visit on 06/09/2022 include documentation from nurse "reached out to patient's hospice team to update them on patient telling me that she was lonely. She really enjoys nursing visits and is looking for more visits, may from volunteer to sit and keep her company". There was not evidence of order or plan of care update for volunteer request/needs. In addition, on nurse visit 05/12/2022 the documentation noted from nurse " Concerned about possible pressure ulcer so area was covered with sure prep and extra sure prep was left so family could place it on throughout the rest of the week" however, there was no evidence of assessment or measurements. Patient #10: The nurse assessment on 06/30/2022 indicated nurse performed wound care on coccyx wound however, there was not evidence of wound assessment or measurements.

Upon patient record review, 12 of 13 records (Patients #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13) 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 #1: This patient admitted with terminal prognosis of multiple sclerosis however, there was no evidence of neurological or neuromuscular problems/interventions/goals. [corrected on site] Patient #2: The record did not contain evidence of patient's advance directives/code status. [corrected on site] Patient #3: The nurse comprehensive assessment on 05/03/2022 indicated the patient had a surgical wound however, there was no evidence on plan of care of wound care problems/interventions/goals. Patient #4: The patient was admitted with terminal prognosis of unspecified sequalae of cerebral vascular disease however, no evidence of problems/interventions/goals for neurological. [corrected on site] Patient #5: The patient admitted for terminal prognosis of Type 2 DM with diabetic neuropathy however, the plan of care did not contain evidence of diabetic problems/interventions/goals. Patient #7: The patient admitted for terminal prognosis of Parkinson's however,the plan of care did not contain evidence of neurological problems/interventions/goals. [corrected on site] Patient #8: The patient admitted with terminal prognosis of protein calorie malnutrition however, the plan of care did not contain evidence of imbalanced nutrition or fatigue r/t metabolic deficiency problems/interventions/goals. Patient #9: The social worker visit on 03/02/2022 indicated pet therapy dog however, there was no evidence on plan of care. [corrected on site] Patient #10: The comprehensive assessment checked the wound box and nurse narrative noted "wounds to bilat arms and St 4 coccyx wound" however, there was no evidence of wound problems/interventions/goals on plan of care. Patient #11: The patient admitted with terminal prognosis of unspecified diastolic heart failure however, the plan of care did not contain evidence of cardiac problems/intervention/goals. [corrected on site] Patient #12: The patient admitted with terminal prognosis of protein calorie malnutrition however, the plan of care did not contain evidence of imbalanced nutrition or fatigue r/t metabolic deficiency problems/interventions/goals. [corrected on site] Patient #13: The patient admitted with terminal prognosis of senile degeneration of the brain however, the plan of care did not contain evidence of neurological problems/interventions/goals. [corrected on site]

Upon patient record review, 1 of 13 (Patient #1) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #1 physician CTI on 06/06 noted, "pain not well controlled at this time" however, plan of care did not contain any problems/interventions/goals for pain.

Upon patient record review, 13 of 13 records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) 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. Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13: The plan of care does not contain evidence of orders for medications. Patient #2: The nurse visit on 06/24 indicated an x-ray was ordered of L hip however, there was no evidence of physician order in record. Patient #3: The nurse visit on 06/21 indicated patient uses "purewick female catheter" however, there was not evidence of this on plan of care.

Upon patient record review, 13 of 13 records (Patients #1,#2, #3, #4, #5, #6 #7, #8, #9, #10, #11, #12, #13) 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 #1: The record contained admission order for hospital bed, wheelchair, over the bed table, and shower bench however the plan of care does not contain evidence of DME. Patient #2: The record contained admission order for hospital bed, over the bed table, bedside commode, shower bench, wheelchair, nebulizer however, the plan of care does not contain evidence of DME. Patient #3: The record contained admission order for hospital bed, over the bed table, bedside commode, oxygen, wheelchair, nebulizer however, the plan of care does not contain evidence of DME. Patient #4: The record contained admission order for hospital bed, over the bed table, bedside commode, pressure relieving mattress, shower bench, walker/cane however, the plan of care does not contain evidence of DME. Patient #5: The record contained admission order for over the bed table however, the plan of care does not contain evidence of DME. Patient #6: The record contained admission order for hospital bed, over the bed table, pressure relieving mattress, low air loss mattress, wheelchair however, the plan of care does not contain evidence of DME. Patient #7: The record contained admission order for hospital bed and on nursing assessment 06/25/2022 "using his front wheeled walker he often stumbles" however the plan of care does not contain evidence of DME. In addition, nurse noted on 07/01/2022 visit that patient has a suprapubic catheter however, plan of care does not contain evidence of this item. Patient #8: The record contained admission order for walker and wheelchair however, the plan of care does not contain evidence of DME. Patient #9: The record contained admission order for hospital bed, over the bed table, shower bench, wheelchair however, the plan of care does not contain evidence of DME. Patient #10: The record contained admission orders for hospital bed, low air loss mattress, over the bed table, oxygen concentrator, and hoyer lift however, the plan of care does not contain evidence of DME. Patient #11: The record contained admission orders for oxygen and walker however, the plan of care does not contain evidence of DME. Patient #12: The record contained admission orders for hospital bed, low air loss mattress, pressure alternating mattress, wheelchair, over the bed table, and oxygen concentrator however, the plan of care does not contain evidence of DME. Patient #13: The record contained admission orders for hospital bed, wheelchair, over the bed table, and bedside commode however, the plan of care does not contain evidence of DME.

Upon client record review, 11 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) 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, 3, 5, 7, 8, 9, 10 The record did not contain evidence that the individualized plan of care was reviewed every 15 days as there were no documented IDG meetings and the IPOC was most recent POC without updates and revisions. Patient #4: The record did not contain evidence that the individualized plan of care was reviewed every 15 days and the record indicated one documented IDG meeting was on 12/15/2021 (which did show evidence that POC was reviewed on that date) and IPOC from 11/30/2021 was most recent POC. Patient #6: The record did not contain evidence that the individualized plan of care was reviewed every 15 days and the record indicated one documented IDG meeting was on 06/01/2022 (which did show evidence that POC was reviewed on that date) and POC from 4/18/2022 was most recent POC. Patient #11: The record did not contain evidence that the individualized plan of care was reviewed every 15 days as IDG meeting was on 04/20/2022 and then none until 06/01/2022 (after this date review was every 14 days).

Upon patient record review, 12 of 13 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) 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. Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 There was not an updated comprehensive assessment documented after the admission comprehensive assessment. Patient #1: Order for hoyer lift on 05/10/2022, however there was no evidence that the POC was updated to include problems, goals, and interventions. Patient #2: Social worker note on 04/08 indicated "MSW brought pet therapy dog and Easter basket from AZ hospice office" however, pet therapy was not on POC. On 06/24/2022 nurse documented patient had a fall and complaining of hip pain so x-ray was ordered however, there was not evidence of an update to problems, goals and interventions. Patient #3: Social worker notes on 05/26 and 06/23 indicated "MSW brought pet therapy dog and Easter basket from AZ hospice office" however, pet therapy was not on POC. The nurse note 06/21 indicated patient uses "purewick female catheter" however, there was not evidence of an update to problems, goals and interventions on the POC. Patient #5: Nursing assessment on 04/14/22, the nurse noted patient had 3 wounds (admitted with one wound) however, there was not evidence of an update to problems, goals and interventions on the POC. Patient #6: Nurse visit 05/12/2022 nurse charted, "concerned about possible pressure ulcer so area was covered with sure prep and extra sure prep was left so family could place it on throughout the rest of the week". There was not evidence of an update to problems, goals and interventions on the POC. Social work note on 06/28/2022 stated "IDG request for mobile ophthalmologist" however there was no evidence of update to POC. Patient #11: The nurse visit on 07/08/2022 indicated "meds refilled this visit. Mediset filled QF. SN refilled mediset this visit." There was not evidence of problems, goals, and interventions for this on the POC.

Upon client record review, 13 of 13 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients #1-#13: The orders for visit frequency for all disciplines were written as frequency for next 15 days, to be reassessed at next IDG: low:____ high:____ Includes PRN. Visits were completed after 15 day window without an updated visit frequency order for each patient. Patient #2: 04/14/2022 nurse assessment noted Calcium alginate applied on wound. No evidence of wound care orders. Patient #6 Nurse visit 05/12/2022 nurse charted, "Concerned about possible pressure ulcer so area was covered with sure prep and extra sure prep was left so family could place it on throughout the rest of the week" however, there was no evidence of order for treatment to ankle. Patient #7: Nurse visit 07/01/2022 indicates "RN changed suprapubic catheter, 16 fr. 10cc balloon". No evidence of order to change suprapubic or for catheter. [corrected on site] Patient #10: Nurse visit 06/30/2022 documented dressed coccyx wound appropriately. No evidence of wound care orders. Patient #11 The nurse visit on 07/08/2022 indicated "meds refilled this visit. Mediset filled QF. SN refilled mediset this visit." No evidence of an order to fill med planner.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 12 applicable (Patients #5, #7, #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #5: The aide plan of care indicated shave PRN, call nurse if new skin problems are noted PRN, and change bed linen weekly and PRN. Patient #7: The aide plan of care indicated bed bath as requested by patient however, the nurse assessment noted the patient was alert and oriented x 2 with confusion and impaired judgement and dementia. The aide plan of care also indicated bed linens change per patient request, and incontinent care/diapers/brief as needed per visit. Patient #11: The aide plan of care indicated shower each visit as needed, clean nails each visit as needed, assist to dress each visit as needed.

Upon patient record review 11 of 12 applicable (Patients #1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12) 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 Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12 All patient records contained aide visit frequency were written as "frequency for next 15 days, to be reassessed at next IDG low:____ high:____ " however, the record did not contain evidence of updated orders or revision to plan of care. The aide visited after the 15 days without orders for these patients. Patient #1: The aide plan of care indicated shampoo/style hair 2 times per week however, the week of 05/15/2022 the aide visited 05/16 and 05/19 and did not shampoo/style hair on 05/19. Patient #2: The aide plan of care indicated to complete skin sheet with each visit, clean/file toenails each visit, and bathe and inspect feet each visit however, the aide note indicated on 07/07 the skin sheet and clean/file toenails was not completed, on 06/30 the skin sheet and bathe/inspect feet was not completed. Patient #3: The aide plan of care indicated complete skin sheet, denture care, social/emotional support, and apply orthopedic/support appliance two times per week. On 06/27, the aide note indicated complete skin sheet or perform denture care was not complete which was 1st of 2 visits that week, on 06/20, the aide note indicated orthopedic/support appliance was not completed which was the 1st of 2 visits this week, and on 06/06 the aide note indicated perform denture care was not completed which was the 1st of 2 visits that week. Patient #4: The aide plan of care indicated complete skin sheet, clean/file toenails/assist with brushing teeth, swab/clean mouth and record most recent BM every visit however, on 07/07 the aide note indicated the skin sheet, clean/file toenails, or record most recent BM was not completed, 06/30 and 06/27 the aide note indicated assist with brushing teeth was not completed, 06/23 and 06/20 the aide note indicated that swab/clean mouth was not completed. Patient #5: The aide plan of care indicates shower 2 times per week, complete skin sheet and comb/brush hair every visit. The aide notes indicated week of 04/3 patient only received one visit on 04/04. Also on 04/04, 04/13, and 04/14 the skin sheet was not completed as indicated per aide note and on 04/15 the aide note did not indicate comb/brush hair was completed. Patient #7: The aide plan of care did not contain evidence for aide to apply lotion, however on aide notes for 07/01 and 07/04 the aide noted "lotion applied to skin". Patient #11: The aide plan of care indicted offer food/fluids, inspect skin check pressure areas each visit however, the aide note indicated on 07/03 and 06/15 the aide did not offer food/fluids and in addition on 06/15 the aide did not inspect skin check pressure areas. Patient #12: The aide note on 07/01/2022 indicated "bed bath due to patient not feeling well per son" however, there was not evidence of bed bath on plan of care or communication with registered nurse.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence the governing body and administrator have assumed responsibility for the oversight of patient care for the hospice agency. Initial and updated comprehensive assessments do not meet the hospice standard. There is no evidence of orders for visits frequencies for all disciplines, orders for medications, orders for DME, and no clearly defined problems, goals and interventions. There is no oversight to ensure the patient needs are being met by the care that is being provided to the patients.

Upon personnel record review, 1 of 9 applicable (Personnel #8) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #8: The record did not have evidence of orientation for the bereavement coordinator role.

Upon patient record review, 5 of 13 (Patients #6, #10, #11, #12, #13) 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 #6: The election of benefit was signed on 04/10/2022, however the certification contained benefit start date of 04/07/2022. Patient #10: The election of benefit was signed on 06/05/2022, however the certification contained benefit start date of 06/06/2022. Patient #11: The election of benefit was signed on 04/01/2022, however the certification contained benefit start date of 04/02/2022. Patient #12: The election of benefit was signed on 06/11/2022, however the certification contained benefit start date of 06/10/2022. Patient #13: The election of benefit was signed on 05/17/2022, however the certification contained benefit start date of 05/14/2022.

Upon patient record review, 1 of 7 applicable records (Patient #11) 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 #11: The record indicated certification period for 2nd benefit period was 06/30/2022-09/27/2022 however, certification listed benefit period dates of 07/01/2022-09/28/2022.

Upon patient client record review, 2 of 13 records (Patient #3, #6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The record did not contain evidence of election statement. Patient #6: The record contained evidence that addendum was requested, addendum was delivered same day as EOB election (04/10/2022) with the non-covered section blank however, medical record indicated coumadin in medication profile is non-covered and there is no evidence of an updated signed addendum in record.

Upon patient client record review, 1 of 13 records (Patient #6) did not have evidence that each patient record contains Advance Directives. Patient #6: The record indicated in MSW comprehensive that patient is a DNR (on file) however, the record did not contain evidence of copy of DNR.

Upon client record review, 1 of 1 applicable (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: The patient elected to revocate however, the record did not contain evidence that the discharge summary included: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders