Every finding on record at Elysian Hospice San Antonio, LLC

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4 - No evidence that the patient choose a healthcare provider/attending physician at time of admit. The line to write in attending physician left blank.

Upon patient record review, 2 of 19 (Patient #1,#6) 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 Patient has Loperamide 2mg tab, 1 tab as directed PRN on MAR. No indicator of what frequency medication should be given. Polyethylene Glycol 17 grams daily PRN ordered. No evidence of instructions on how/what to use to dilute powder. Corrected on site. Patient 6 Patient has Miralax powder on MAR to give 17grams daily by mouth PRN for constipation. No evidence of instructions on how/what to use to dilute powder. Corrected on site.

Upon patient record review, 2 of 19 (Patient #1 and 6) 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 Patient has orders for Loperamide 2mg tab, 1 tab as directed PRN. No indicator of what frequency medication should be given. Polyethylene Glycol 17 grams daily PRN ordered. No evidence of instructions on how/what to use to dilute powder. Corrected on site. Patient 6 Patient has orders for Miralax powder ordered to give 17grams daily by mouth PRN for constipation. No evidence of instructions on how/what to use to dilute powder. Corrected on site.

Upon patient record review, 17 of 19 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 19) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 19 - Medical director copied and pasted RN admission narrative into his CTI narrative. No original documentation from the medical director.

Upon patient record review, 7 of 19 (Patients #2,3,4,6,7,9,11) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients 2,3,4,6,7,9,11 Evidence was seen that Medical Director copied and pasted the complete RN recertification narratives into his recertification CTI narrative. No original documentation from the medical director seen.

Upon patient client record review, 2 of 19 (Patient #4,6) 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 4 - No evidence that the patient choose an attending physician at time of admit. The line to write in attending physician left blank. Patient choice statement has POA listed as patient. Election of benefits has POA listed as patient. Start of care date missing from election of benefit statement. Corrected on site. Patient 6 - Start of care date missing from election of benefit statement. Corrected on site.

Upon client record review, 1 of 19 (Patient #19) 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 19 No evidence that a copy of the discharged summary was sent to the attending physician.

Upon client record review, 1 of 19 (Patient #18) did not have evidence that the discharge summary includes all required information. Patient 18 No evidence that full discharge summary was completed. Discharge summary did not include discharge instructions, no discharge physician order, no summary of the patient's stay including treatments, symptoms and pain management, and evidence that discharge summary was sent to attending physician.

Upon client record review, 2 of 19 (Patient #4, 8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 4 During facility visit, PT at patient bedside. Nursing home chart has PT ordered 3 times weekly. PT not ordered on hospice chart. Corrected on site. Patient 8 Visit frequency for SW ordered as once monthly on plan of care. No evidence SW visit for the month of March was completed. No missed visit note or coordination entered.