Every finding on record at Effort Hospice Inc

Upon client record review, 2 of 8 (Patient #6, 7) 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: The patient revoked hospice services effective 12/11/21. There was no documented evidence of the discharge summary being sent to the attending physician. Patient 7: The patient revoked hospice services effective 12/11/21. There was no documented evidence of the discharge summary being sent to the attending physician.

Upon client record review, 3 of 8 (Patient #6, 7, 8) did not have evidence that the discharge summary includes all required information. Patient 6, 7, 8: The discharge order present in the patient medical record dated 12/11/21 was verified to also be utilized as the discharge summary sent to the MD. The document was found to lack the patients latest physician orders to include medications and treatments.

Upon patient record review 1 of 5 (Patient #3) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #3: No evidence of a Spiritual Care assessment being completed.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Social Worker frequency ordered to be 1 time a month. No evidence to support a visit was made in November.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, #5) 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. Patient #1, #2, #3, #4, #5 - CTI signature box for Hospice Physician contains a signature that is illegible with no credentials or printed name. Unable to determine who signed the form. Patient #3: Benefit period date on plan of care written over and not noted as an error. Date illegible as to whether it is 11/25 or 11/26. Cert period start date on the Recertification CTI and POC were incorrect - Written as 11/26/21 and should be 11/27/21. Patient #4: Cert period start date on the Recertification CTI and POC incorrect. Written as 11/26/21 and should be 11/27/21.