Every finding on record at Eldercare Corp

Upon patient record review, 2 of 19 (Patient #9) 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 #9 Facility listed aspirin 81 mg once daily on Rx profile however, the agency medication profile did not include this. In addition, hospice agency had Ativan and Lorazapam listed on med profile with same dose and frequency. This was duplicate medications.

Upon patient record review, 1 of 19 (Patient #11) 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 #11: SOC 7/31/23 The wound treatment order for left buttock abscess, cleanse with ns, pat dry, apply ATB, cover with border gauze dressing daily and prn. The order for Rt buttock stage 2 was cleanse with NS, pat dry, apply medi-honey, cover with border gauze dressing daily and prn. There was no evidence of a PRN qualifier for either order. Patient has foley catheter however, there was no order to specify foley size, balloon, frequency or circumstances for change. Patient had hospital visit 8/25/23 when foley was discontinued but no update to IDG POC regarding removal.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient#11: Patient admitted 7/31/23 with foley catheter and was hospitalized 8/25/23 when foley was discontinued however, there was no evidence of update to POC regarding removal/absence of Foley.

Upon client record review, 2 of 14 (Patient #3, 14 ) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: SOC 8/3/23. Initial SC frequency for 1/mo and 1 prn every 30 days. There was notation 8/8/23 that patient declined SC services. No visits provided, but SC frequency was not updated on POC since admission, remaining 1x/month in frequency listing. Patient #14: SOC 8/15/23. Initial SC frequency for 1x/month. SC documented 8/17/23 that patient declined services. Plan of care frequency was not updated to reflect declination, but remained 1x/month in listed frequencies.

Upon personnel record review, 1 of 17 (Personnel #7 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #7: The competency form used by the agency does not specify all 3 types of shampoo, but simply shampoo. Therefore, competence in all (3) cannot be verified as documented.

Upon patient record review 4 of 19 (Patient #5, 6, 7, 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 #5: SOC 6/23/22. During patient visit, the HA set up for shower. In reviewing HA assignment with the aide on site, noted that bed bath is assigned by RN. Patient #6: SOC 8/1/23 with initial HA frequency of 2x/wk. No visits provided. 2x/wk frequency continued on IDG POC until 9/20/23, when updated to reflect 8/3/23 order documenting patient declined HA 8/3/23. Patient #7: SOC 7/14/23. Two "Visit Summary Notes" (hard copies uploaded to EMR) are generalized and not specific to task assigned/completed, notes July 18, 20, 21, 23 are incomplete and not specific to task assigned vs. tasks completed and notes on 8/15 and 8/25/23 include narrative for "Complete ADLs done". Patient #13: SOC 8/15/23 HA 2x wkly. There was only evidence of completed visit notes for 10/6 and 10/19.

Upon patient client record review, 1 of 19 (Patient #14 ) 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 #14: Election Statement effective date is written as 8/15/24 rather than 8/15/23.

Upon patient client record review, 5 of 19 (Patient #5, 6, 7, 12, 15) 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 #5: EMR documents include (2) sets of admission papers which are both are signed by responsible party with same time stamp (6/16/23 1121 PDT) however, one (blank set) has blank effective date and the completed set has 6/23/26 as effective date. Patient #6: Medication profile lists Pravastatin Sodium 40 mg 1 tab oral 1 times a day for other symptom (document) (40 mg tablet). The nurse failed to write indications/symptoms in "document" space. On the election statement section for patient physician choice there were two physician listed. Patient #7: The comprehensive assessment addresses HA frequency assignment of 2x/wk. Nursing summary narrative of same document, refers to HA frequency of 3x Patient #12, 15: CTI signature is Michael Katrine Medical Director, who is identified in personnel roster as hospice physician but not Medical Director. Interview with staff response is that admin support staff inadvertently set up MD signature as Medical Director. Was corrected on site.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency reportedly underwent Administrator change 9/11/23. The agency appropriately reported change to California Dept. of Public Health, but had not yet reported to CMS directly.