Every finding on record at Caring Angels Hospice, Inc

Upon patient record review, 3 of 5 (Patient # 1, 2, 3) did not have evidence that the patient chooses a health care provider, including an attending physician. The hospice election of benefit did not have the section where the patient/patient representative chooses an attending physician completed.

Upon patient record review, 1 of 5 records (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 medications and treatments. Patient 1: The initial plan of care physician order included an order for Nitrostat 0.4mg, dose 1 tab, instructions take 3 tabs every 5 minutes if not relieved. The order was consistent with the medication profile. The Medication profile was correct with instructions to take 1 tab every 5 minutes times three if not relieved to call the hospice or 911.

Upon patient record review 1 of 1 applicable (Patient # 5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group Patient 5: The medical record contained initial physician order and plan of care documenting aide services were refused. The care plan document, IDT documentation signed by physician, and aide visit documentation identify patient was receiving aide services twice weekly without a physician order for the services.

Upon patient client record review, 3 of 5 records (Patients #1,#2,#3) did not have evidence that each patient record contains signed election statement in accordance with 418.24. Patients 1, 2, and 3: The medical records contain election of benefit forms with section empty that allows patient/representative to elect attending physician or choose to decline choice for election.

Upon patient client record review, 2 of 5 records (Patients #2,#4) 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. Patients 2 and 4: The medical records contain consents signed by patient/representative with services on page 4 stating aide frequencies planned for twice weekly. Initial physician orders and plan of care documented that aide services were refused. Leadership confirmed data entry on consents was inaccurately entered and patient/representative did not elect for services.