Every finding on record at Centric Care Hospice Inc

Upon patient record review, 1 of 5 records (Patient #1) 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 #1: The medication profile contains Furosemide 20mg 1 daily as needed. There was not evidence of a reason for when to use the medication.

Upon patient record review, 1 of 5 records (Patient #1) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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: The assessments conducted by the RN on 11/15/24, 11/29/24 and 12/14/24 indicate that the patient has aspiration precautions. This is not reflected in the plan of care.

Upon patient record review, 1 of 5 records (Patient #1) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicates an order for Furosemide 20mg 1 daily as needed. There was not evidence of a reason for when to use the medication.

Upon patient record review, 2 of 5 records (Patient #2,#4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #2: The plan of care, dated 10/9/24, indicated that the patient had a stage 2 pressure injury and goals and interventions were developed for this problem. Assessments conducted by the nurse on 11/29/24-12/10/24 do not indicate the presence of a wound. Goals and interventions remain active on the plan of care for this issue. Patient #4: The record indicated that the patient had a UTI and was on Keflex from 11/24/24-12/2/24. UTI remained on the plan of care with active goals and interventions that had not been resolved.

Upon patient record review, 1 of 5 records (Patient #1) 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 specific patient care instructions including alerts and precautions 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 #1: The assessments conducted by the RN on 11/15/24, 11/29/24 and 12/14/24 indicate that the patient has aspiration precautions. This is not reflected in the aide plan of care.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. Agency had table top exercises however no evidence of a community-based drill for the past 3 years.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review, 7 of 15 (Patient #1, 2, 3, 4, 6, 7, 9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1, 2, 3, 4, 6, 9 elected the hospice MD as the attending, and certifications of terminal illness were received from and sent to the referring physician which the patient did not elect as their attending physician. Patient 7 no evidence the patient was involved in electing an attending physician.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence of the appropriate documentation for release of confidential information. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence that the patient received information about the services covered under the hospice benefit. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review, 1 of 15 (Patient #7) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3.

Upon patient record review 3 of 15 (Patient #4, 6, 10) 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 4 admitted on 9/30/24, spiritual assessment completed on 10/9/24. Patient 6 admitted on 7/23/24, spiritual assessment completed on 7/30/24. Patient 10 admitted on 10/2/24, spiritual assessment completed on 10/8/24.

Upon patient record review 2 of 15 (Patient #2, 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 2 and 12 no evidence of an initial spiritual assessment.

Upon patient record review, 10 of 15 (Patient #1, 3, 5, 7, 8, 9, 10, 11, 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 1 oxygen ordered 2-5LPM as a treatment, no evidence of oxygen on medication profile. Patient 3 Tylenol 500mg 2 tab Q6h prn and Tylenol 650mg rectal Q6h prn, no evidence of the max allowable dose to exceed. Patient 5 nursing visit on 10/4/24 documents the use of Milk of Magnesium, this is not on the medication profile. Patient 7 Polyethylene Glycol 17g on medication profile, no evidence of mixing instructions or how to dilute. Duplicate entries on medication profile for both Tylenol 650mg sup Q6h prn and Hyoscyamine 0.125mg Q4h prn. Patient 8 nursing visit on 3/12/24 documents oxygen 3LPM NC continuous in use, no evidence of oxygen on medication profile. Patient 9 nursing visit on 10/19/24 documents oxygen 2-5LPM NC in use, no evidence of oxygen on medication profile. Patient 10, 12 oxygen ordered 2-5LPM NC under treatment, no evidence of oxygen on medication profile Patient 11 nursing visit on 4/9/24 documents oxygen 2LPM NC continuous in use, no evidence of oxygen on medication profile. Patient 13 Atropine ophthalmic 1% 2 drops route listed as ophthalmic every 3 hours for secretions, no evidence of a clear route to administer as secretions would be oral administration.

Upon patient record review, 4 of 15 (Patient #4, 6, 10, 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 4 admitted on 9/30/24, bereavement risk assessment completed on 10/9/24. Patient 6 admitted on 7/23/24, bereavement risk assessment completed on 7/30/24. Patient 10 admitted on 10/2/24, bereavement risk assessment completed on 10/8/24. Patient 12 no evidence of an initial bereavement risk assessment.

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

Upon patient record review, 1 of 15 (Patient #3) 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 no evidence of wound assessment for the right upper back and right buttock wounds by the nurse during the visits on 10/30/24, 11/1/24, 11/5/24, 11/9/24.

Upon patient record review, 8 of 15 (Patient #1, 3, 6, 7, 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 taking Levetiracetam for seizures, no evidence of seizure precautions on the care plan. Patient 3 mechanical soft diet ordered and nursing visit 10/10/24 documented high risk for aspiration, no evidence of aspiration precautions on the care plan. Patient 6 pureed diet ordered and aide care plan includes aspiration precautions, no evidence of aspiration precautions on care plan. Patient 7 on oxygen care plan includes an oxygen safety care plan, however no evidence of a respiratory care plan or oxygen utilization care plan. Patient 10 mechanical soft diet ordered and aide care plan includes aspiration precautions, no evidence of aspiration precautions on care plan. Patient 11 chopped diet and nursing documentation of risk for aspiration, no evidence of aspiration precautions on care plan. Patient 12 pureed diet and nursing documents risk for aspiration, no evidence of aspiration precautions on the care plan. Patient 13 has spiritual care ordered and completed initial assessment, no evidence of a spiritual care plan to include problems, goals, and interventions.

Upon patient record review, 7 of 15 (Patient #1, 7, 8, 9, 11, 12, 13) 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, 9 IPOC includes SW/SC 1 time then prn, no routine frequency and no quantity for the prn. Patient 7, 8, 11, 12, 13 IPOC Bereavement Coordinator (BC) ordered one time then prn, no routine frequency and no evidence of a quantity for the prn.

Upon patient record review, 9 of 15 (Patient #3, 5, 6, 7, 8, 9, 10, 11, 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. Patient 3 Tylenol 500mg 2 tab Q6h prn and Tylenol 650mg rectal Q6h prn, no evidence of the max allowable dose. Two wound care ordered entered on 10/10/24 for locations on the right arm do not include a frequency for the wound care. Wound care order on 10/30/24 for the right upper back does not include a frequency. Wound care order on 11/5/24 for right buttock does not include a frequency. Patient 5 nursing visit on 10/4/24 documents the use of Milk of Magnesium, no evidence of an order for MOM. Patient 6 order on 7/29/24 for wound stage 1 left heel cleanse the area pat dry, apply barrier cream off load heel and cover with foam dressing, no evidence of what to cleanse the wound with and no evidence of a frequency. Patient 7 Polyethylene Glycol 17g ordered, no evidence of mixing instructions or how to dilute. Duplicate orders for both Tylenol 650mg sup Q6h prn and Hyoscyamine 0.125mg Q4h prn. Patient 8 nursing visit on 3/12/24 documents oxygen 3LPM NC continuous in use, no evidence of an order for oxygen. Patient 9 nursing visit on 10/19/24 documents oxygen 2-5LPM NC in use, no evidence of an order for oxygen. Order on 10/19/24 for wound care to the right arm does not include a frequency for the wound care. Patient 10 RN visit 10/2/24 documents 16fr/10cc balloon foley, no evidence of an order for the foley management. Patient 11 nursing visit on 4/9/24 documents oxygen 2LPM NC continuous in use, no evidence of an order for oxygen. Patient 13 Atropine ophthalmic 1% 2 drops route listed as ophthalmic every 3 hours for secretions, no evidence of a clear route to administer as secretions would be oral administration.

Upon patient record review, 7 of 15 (Patient #1, 2, 5, 6, 8, 11, 12) 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 initial nursing visit documents over bed table, walker, wheelchair and suction in use, no evidence an order for the DME. Patient 2 initial nursing visit documents bed, over bed table, no evidence of an order for the DME. Communication notes on 11/6 and 11/8 document ordering a walker, wheelchair, shower chair and bedside commode, no evidence of an order for these. Patient 5 initial nursing visit documents a shower chair, no evidence of an order for the DME. Patient 6 hoyer lift in use, no evidence of a order for the DME. Patient 8 initial nursing visits documents wheelchair in use, no evidence of an order for the DME. Patient 11 initial nursing visit documents wheelchair in use, no evidence of an order for the DME. Patient 12 initial nursing visit documents wheelchair and over bed table, no evidence of an order for the DME.

Upon client record review, 8 of 15 (Patient #1, 2, 3, 4, 5, 6, 11, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 IPOC includes VS every visit with parameters, no vital signs documented on the 11/8/24 nursing visit. Patient 2 IPOC includes an order to report oxygen saturation <90% to the MD. Nursing visit on 11/4/24 documented oxygen saturation of 80% and no documentation it was reported to the MD. Patient 3 order to report oxygen saturation of <90% to MD, nursing visits on 10/22/24, 11/5/24 document oxygen saturation at 81% without notification to the MD. Order to measure wounds weekly, no evidence of wound measurements for right buttock and right upper back during nursing visits 10/30/24, 11/1/24, 11/5/24, 11/9/24. Patient 4 vital signs ordered to be completed every nursing visit, no vitals signs completed on the 11/11/24 prn nursing visit. Patient 5 nursing visit frequency ordered 2x week, nursing visit notes on 10/17/24, 10/23/24, 10/25/24 are all blank notes, no evidence a visit completed on these days in order to meet visit frequency. Nursing visits on 10/4/24, 10/9/24, 10/11/24, 10/15/24 document wound care provided to right ankle skin tear, no evidence of an order for the wound care. Patient 6 social work ordered 1x month on 7/23/24, no evidence of a visit for the month of September or refusal. SN ordered on 7/23/24 for 2x week and 3prn. Routine LVN visits completed on 10/28/24, 10/29/24 and 11/1/24. Only one nursing visit on 10/8/24 by the RN, no evidence of a second visit or refusal this week. Intervention on care plan to change foley monthly no evidence of a foley change from 8/30/24-10/29/24. Patient 11 order for 16fr/10cc balloon foley. Nursing visit on 4/12/24 documents 16fr/30cc balloon placed, no evidence of an order for 16fr/30cc balloon. Patient 12 order on 2/27/24 for BC (Bereavement Coordinator) x1 eval, no evidence of a visit by the BC.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. Agency had two performance improvement projects in 2023 one on handwashing and one on bag technique, no patient specific QAPI projects for 2023, or 2024.

Upon home visit observation 2 of the 3, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 4, the RN placed her folder on the patient's table without a barrier and without cleaning prior to placing the folder on the table. Patient 5, the aide placed her bag on a chair without cleaning the surface or a barrier prior to placing her bag on the chair.

Upon patient record review, 2 of 15 (Patient #12, 13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 12 died 4/1/24, and one month bereavement letter was sent on 7/16/24. Patient 13 died on 1/18/24, the 6 month letter was sent on 4/16/24 and the 9 month letter sent on 7/16/24.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 10 of 15 (Patient #1, 2, 3, 5, 6, 9, 10, 11, 13, 14) 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 1 aide care plan included chair to bed, turn and reposition, change linen all without a frequency. No evidence of identified seizure precautions. Patient 2 aide care plan included record bowel movement and change linen without a frequency. Patient 3 aide care plan included turn and reposition, record bowel movement, and change linen without a frequency. Patient 5 aide care plan included record bowel movement and change linen without a frequency. No evidence of identified oxygen precautions. Patient 6 aide care plan included turn and reposition, measure urine output, empty collection bag, record bowel movement, and change linen without a frequency. No evidence of identified seizure precautions. Patient 9 aide care plan included change linen and turn and reposition without a frequency. Patient 10 aide care plan included turn and reposition, measure output, empty collection bag, and change linen without a frequency. Patient 11 aide care plan included turn and reposition, empty collection bag, record bowel movement, and change linen without a frequency. Aide care plan included diet as tolerated and did not include the update on 4/16/24 to chopped and aspiration precautions. No evidence of identified bleeding precautions. Patient 13 aide care plan included turn and reposition, pajamas, change linen without a frequency. No evidence of identified oxygen precautions. Patient 14 aide care plan included turn and reposition, pajamas/gown, and change linen without a frequency.

Upon patient record review 5 of 15 (Patient #1, 2, 3, 4, 13) 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 1 order on 11/8/24 for aide 2x week, no evidence of 2 aide visits the week of 11/8 or refusals. Patient 2 order on 11/4/24 for aide 2x week, visit on 11/5 refused, no evidence of a second visit or refusal. Patient 3 order on 10/10/24 for aide 2x week, no evidence of 2 aide visits the week of 10/10/24 or refusals. Patient 4 order on 9/30/24 for aide 1x week, no evidence of a visit or refusal the week of 9/30. Patient 13 order on 1/12/24 for aide 1x week, no evidence of a visit or refusal the week of 1/12.

Upon personnel record review, 1 of 14 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel 2 hired 2/5/24 no evidence of a job description or orientation for the role of Alternate Administrator.

Upon contract review, 1 of 4 (Wound pro/Omni Care) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency was utilizing Wound pro/Omni care wound companies to provide debridement wound care related to the terminal illness to patient 8 and the agency did not have a contract with the wound care companies. The hospice does not have any current patients receiving services from these wound care companies.

Upon patient client record review, 13 of 15 (Patient #3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15) 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, 13, 14, 15 effective date of election is blank, elected to receive notice of non-covered and it was not provided, and the election does not contain the name or contact information for the BFCC-QIO. Patient 4, 6, 10, 12 effective date of election is blank and the election does not contain the name or contact information for the BFCC-QIO. Patient 5 elected to receive notice of non-covered and it was not provided, and the election does not contain the name or contact information for the BFCC-QIO. Patient 7, 8, 9, 11 the election does not contain the name or contact information for the BFCC-QIO. Patient 7 The wife signed admission documents, no evidence the patient was involved in the discussion or received the information. Patient is alert and oriented at admission x3. Initial nursing visit documented hospice services and admission consents discussed and explained to wife and children, expressed understanding, wife signed consents. Under neuro assessment for the patient he is documented as weak yet alert and oriented to person, place and time, communication and speech are normal. No documentation of patient involvement in the admission consent process.

Upon patient client record review, 1 of 15 (Patient #3) 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 3 nursing visit on 11/9/24 documented wound care per orders and did not document the detail of the care provided.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. In review of the patient handbook, there was not evidence that information was in the handbook on management and disposal of controlled drugs, upon interview with administrator stated that was removed from the patient handbook but would be included moving forward.

Upon client record review, 15 of 15 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. No documentation that management and disposal of controlled drugs was provided to the patient/family.

Observed in Emergency Management Session. During the Emergency Management Plan session, it was noted the organization had not ensured the Emergency Plan included patients in need of evacuation due to their medical or behavioral condition or home environment. For example: review of HV# 1, HV# 2, and HV# 3's individual emergency plan during the home observations, revealed documentation the organization would assist with evacuation. However, review of the Emergency Management Plan revealed no documentation of patients in need of evacuation assistance. This was reviewed and discussed with Leadership and validated.

Observed in Record Review. In 1 of 2 patient records reviewed with revocation, During RR# 1's patient record review, it was noted the patient had revoked hospice. However, the revocation statement could not be found. This was reviewed and discussed with Leadership and validated.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, and RR# 2's patient records review, it was noted the organization had not ensured the bereavement assessment was completed by the medical social worker, as required by policy. For example: review of the Initial bereavement assessments revealed the chaplain completed the assessments. This was reviewed and discussed with Leadership and validated.

Observed in Record Review. In 1 of 5 patient records reviewed, During HV# 2's patient record review it was noted the organization had not ensured the plan of care was based patient's goals and the time frames, settings, and services required to meet those goals. For example: during HV# 2's home observation it was noted the patient was ambulatory and able to transfer independently. Review of HV# 2's patient record revealed HV# 2's terminal diagnoses as end stage heart disease. Review of the plan of care revealed under, Altered cardiovascular status related to heart failure documentation of a goal that the patient would be free from injury related to bedbound status. This was reviewed and discussed with Leadership and validated.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV# 1, HV# 2, and HV# 3's home observation, it was noted the staff had not followed the contact (wet time) as specified by disinfectant manufacturer's IFU. For example: during HV# 1's home observation the licensed vocational nurse (LVN) cleaned the vital sign equipment with a Sani-cloth and after cleaning each piece of the equipment the LVN immediately placed each piece of equipment into the same plastic bag. During HV# 2's home observation the LVN cleaned the vital sign equipment with an alcohol wipe and after cleaning each piece of the equipment the LVN immediately placed it into the same plastic bag. During HV# 3's home observation the home health aide (HHA) cleaned the vital sign equipment with an alcohol wipe and after cleaning each piece of the equipment the HHA immediately placed it into the same plastic bag. This was discussed with the LVN and Leadership and validated.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 1's patient record review, it was noted that neither the medical director or the physician designee had reviewed and provided an initial written certification of terminal illness. For example: review of the patients record revealed no initial written certification of terminal illness by the Medical Director or physician designee. This was reviewed and discussed with leadership and validated.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, and RR# 2's patient records review, it was noted the organization had not ensured the patients' records contained information that reflected the care, treatment, or services. For example: review of HV# 1, HV# 2, and HV# 3's patient record revealed no documentation of a physician order for hospice referral. Review of HV# 1, HV# 2, RR# 1, and RR# 2's patient record revealed no documentation on the Election of Benefit date. During HV# 2's home observation the licensed vocational nurse (LVN) completed a review of the medication HV# 2 was taking and the medication profile. During the medication review it was noted and the medication in the home did not match the organization's medication profile. For example: review of the medications the patient was currently taking included Potassium 10 mEq twice daily, Review of the medication profile failed to reveal Potassium. HV# 2 shared he/she had been taking potassium for sometime. This was reviewed and discussed with Leadership and validated.