Every finding on record at Brytelyte Homecare LLC

Upon patient record review 8 of 16 (Patient #1, #2, #3,#4,#6, #10, #11, #12) 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 #1, #3, #4, #6, #10: There was no evidence of a psychosocial assessment completed within 5 days of the admission. Patient #2, #12: There was no evidence of a psychosocial assessment or spiritual assessment completed within 5 days of the admission. Patient #11: There was no evidence of a spiritual assessment completed within 5 days of the admission.

Upon patient record review, 4 of 16 (Patient #2,#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 Patient #2: The MD recertification narrative indicated the patient was using oxygen at 2L per NC. However, there was no evidence of O2 2L per NC on the medication profile. Patient #4: The written Cert by the MD indicated the patient was on O2 2L NC. There was no evidence of O2 on the medication profile. Patient #5: Per the MD Cert and the admission assessment both dated 4-7-23, the patient was using O2 up to 3L per NC. There was no evidence of O2 on the medication profile. Patient #9: Per the MD Cert on 05-07-24 the patient was using O2 at 2L NC. There was no evidence that O2 was on the medication profile.

Upon patient record review, 5 of 16 (Patient #2, #3, #4, #6, #12) 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. Patient #2, #3, #4, #6, #12: There was no evidence of a bereavement assessment completed within 5 days.

Upon patient record review, 4 of 16 (Patient #4,#5,#6,#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. Patient #4,#5,#6,#9: The HIS indicated a bowel regimen was part of the plan of care and emergency kit was ordered, but there was no evidence of an order for stool softner.

Upon patient record review 1 of 16 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2:There was no evidence of an aide supervisory visit by the RN after 06/04/24 until 08/05/24 while the aide continued to visit the patient 2 x per week.

Upon patient record review, 1 of 16 (Patient #8) 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 #8: There was no evidence of a narrative which included subjective and objective clinical findings, current medication and treatment orders, or medical management of the patient's condition on the written certification for BP 02-14-22 - 05-14-22.

Upon patient record review, 1 of 16 (Patient #13) 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 #13: There was no evidence of a date after the MD signature on the written certification and F2F documentation for cert period starting 09-29-23.

Upon patient record review, 2 of 16 (Patient #1,14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1: There was no date evidenced after the MD signature on the verbal or written certification statements for the admission. Patient #14: There was no evidence of a date after the MD signature for cert period starting 05-06-24.

Upon patient record review, 2 of 16 (Patient #5,#11) 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 #5: There was no evidence of a date for the MSW signature on the MSW assessment of 4-10-23. Patient #11: There was no evidence of a date after the signature of the MSW for assessment of 01-17-23.

Upon observation, there was no evidence of patient records were retained for a minimum of six years from the date of the most recent discharge or the death of the patient. Due to no active patients and no bereaved upon arrival at survey site, I asked client for records from last survey in 2021 which included a bereaved patient. The agency was unable to obtain the records before my departure instructing me that obtaining records from storage required 14 days advance notification.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #4: There is no evidence the hospice forwarded a transfer summary to the transferring facility.

Upon patient record review, 4 of 16 (Patient #6, #7, #8, #14) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #6, #7, #8, #14: There is no evidence of a discharge summary forwarded to the attending physician.

Upon patient record review, 14 of 16 (Patient #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) did not have evidence that the discharge summary includes all required information. Patient #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13 #14, #15: There is no evidence of a discharge summary that included a summary of care and treatments, or the latest MD orders.