Every finding on record at Carewell Hospice

Upon patient record review, 3 of 15 (Patient #1,2,3) 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 #1 Certification period #4 began 2/26/25, the face-to-face was completed timely, however; the MD narrative was not completed until 3/27/25. Patient #2 Certification period #5 began 2/24/25, the face-to-face was completed timely, however; the MD narrative was not completed until 3/27/25. Patient #3 Certification period #6 began 3/12/25, the face-to-face was completed timely, however; the MD narrative was not completed until 3/27/25.

Upon patient record review, 9 of 15 (Patient #7,8,9,10,11,12,13,14,15) did not have evidence that the discharge summary includes all required information. Patients #7-15 did not have complete discharge summaries. The summaries contained date and reason for discharge only. Education provided on the required documentation.

Upon patient record review, 1 of 5 records (Patient #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 3: Order dated 3/13/2021 Vitamin A&D, triple antibiotic ointment apply to affected area for rashes as needed. There was no evidence of a location. Corrected on site. Order dated 3/13/2021 Triamcinolone 0.1% apply to affected area as needed for rashes. There was no evidence of a location. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, and 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: On admission SN visits ordered 1x week and PRN. There was no evidence of the quantity of PRN visits. Corrected on site. Patient 2: On admission SN visits ordered 1x week and PRN. There was no evidence of the quantity of PRN visits. Corrected on site. Patient 3: On admission SN visits ordered 1x week and PRN. There was no evidence of the quantity of PRN visits. Corrected on site. Patient 4: On admission SN visits ordered 1x week and PRN. There was no evidence of the quantity of PRN visits. Corrected on site. Patient 5: On admission SN visits ordered 1x week and PRN. There was no evidence of the quantity of PRN visits.

Upon patient record review, 1 of 5 records (Patient #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 3: Order dated 3/13/2021 Vitamin A&D, triple antibiotic ointment apply to affected area for rashes as needed. There was no evidence of a location. Corrected on site. Order dated 313/2021 Triamcinolone 0.1% apply to affected area as needed for rashes. There was no evidence of a location. Corrected on site.

Upon client record review, 1 of 5 records (Patient # 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Admit order dated 2/1/2022 RN frequency 1x per week and PRN. There was no evidence of a visit the week of 2/6/2022.