Every finding on record at First American Hospice, Inc

Upon patient record review, 10 of 14 (Patient #1,3,4,5,7,8,9,11,12,14) 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 #1,3,4,5,7,8,9,11,12,14, No bereavement assessment completed

Upon patient record review, 1 of 14 (Patient #4) 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 #4, DME supply listed oxygen concentrator, patient did not have oxygen order or need for oxygen.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, 2, 3, LVN did not always sanitize hands going in and out of the clean area of her nursing bag.

Upon patient record review 2 of 14 (Patient #10,14) 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 #10, aide frequency 2x/week, only 1 visit the first week on 3/23/23 Patient #14, aide frequency 2x/week, only 1 visit the first week on 2/12/23

Upon patient client record review, 6 of 14 (Patient #1,2,4,5,6,9) 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 #1,2,5,6, IDG note on 4/6/23, no MD signature. Patient #4, IDG note 12/1/22, no RN signature Patient #9, IDG note 3/22/23, no RN signature