Every finding on record at Billet Hospice Inc, Phoenix

Upon patient record review 1 of 14 (Patient #10) 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 #10-Evaluation visit was done on 03/21/25 prior to admission on 03/25/25 and nurse did not complete an initial assessment within 48 hours after the election of hospice on 3/25/25.

Upon patient record review 3 of 14 (Patient #9,12,14) 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. #9-The patient was admitted on 10/10/24. The spiritual care assessment was completed on 10/26/24. #12-The patient was admitted on 11/20/24. The spiritual care assessment was completed on 11/27/24. #14-The patient was admitted on 02/17/24. The spiritual care assessment was completed on 03/03/24.

Upon patient record review 1 of 14 (Patient #6) 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. #6-There was no evidence of a spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment.

Upon patient record review, 4 of 14 (Patient #1,4,5,9) 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 #1-The medication profile dated 05/03/25 includes an order for Tolnaftate Cream 1%, 1 application daily to affected area. The order does not specify a site for application. Lidocaine pain relief patch 4%, apply 1 patch daily, 12 hrs on and 12 hrs off. The order does not specify a site for application. #4-The medication profile dated 03/21/25 includes an order for Nystatin powder, apply twice daily to affected area. The order does not specify a site for application. #5-The medication profile dated 03/12/25 includes an order for Lidocaine patch 4%,1 patch daily to affected area, 12 hrs on and 12 hrs off. The order does not specify a site for application. #9-The medication profile includes an order written on 01/16/25 for Nystop Ext Powder10000U/GM, 1 application daily to affected area. The order does not specify the site for application.

Upon patient record review, 4 of 14 (Patient #1,4,5,9) 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. #1-The plan of care dated 05/03/25 includes an order for Tolnaftate Cream 1%, 1 application daily to affected area. The order does not specify a site for application. Lidocaine pain relief patch 4%, apply 1 patch daily, 12 hrs on and 12 hrs off. The order does not specify a site for application. #4-The plan of care dated 03/21/25 includes an order for Nystatin powder, apply twice daily to affected area. The order does not specify a site for application. #5-The plan of care dated 03/12/25 includes an order for Lidocaine patch 4%,1 patch daily to affected area, 12 hrs on and 12 hrs off. The order does not specify a site for application. #9-The plan of care includes an order written on 01/16/25 for Nystop Ext Powder10000U/GM, 1 application daily to affected area. The order does not specify the site for application.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #10-Evaluation visit was done on 03/21/25 prior to admission on 03/25/25 and wound care was performed on the evaluation without an order or consents being signed.

Upon patient record review 1 of 1 applicable (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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4- Aide visits on 1/3/22, 1/6/22, 1/10/22, and 1/13/22 documented assisted with ambulation. Assist with ambulation was not included on the aide care plan.