Every finding on record at Conway Medical Center

Upon patient record review, 1 of 8 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Notice of election form did not identify the patient's chosen physician.

Upon patient record review, 1 of 8 (Patient #1) 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 Upon patient record review the psychosocial (SW) or SC assessment was completed on 12/29/20 with SOC dated 12/23/20 therefore exceeding 5 day window..

Upon patient record review, 1 of 8 (Patient #2) 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.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. The use of PRN for tasks is not acceptable. Patient #6 The aide assignment completed 2/20/19 to date reads bed bath and foot care q24hr and prn, oral care q shift and prn, perineal care q12hr and prn and shampoo q3days and prn.

Upon personnel record review, 1 of 1 applicable (Personnel #2 ) did not have evidence the alternate administrator had a signed job description for this role.

Upon patient client record review, 1 of 8 (Patient #1) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #1 There is no evidence of signed election statement identifying physician or date for the 12/23/20 SOC.

Upon observation, there was no evidence there is a copy of the CLIA certificate for the laboratory used for specimen testing. The organization utilizes Select Laboratories-SC LLC and contains no evidence of a CLIA certificate to date.