Every finding on record at First Choice Healthcare, Inc

Upon patient record review 4 of 14 (Patient #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial and emotional 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. Patients #6 &13: Spiritual assessment was not completed by any discipline within 5 days of SOC. Patient #9: Spiritual assessment was not completed by any discipline within 5 days of SOC. Patient #10: Psychosocial assessment was not completed by any discipline within 5 days of SOC (10/24/23).

Upon patient record review, 2 of 14 (Patients #2 and 4) 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 #2: The medication profile indicated to administer Acetaminophen 650mg every 4 to 6 hours routine. The hospice eligibility form stated this was PRN not Routine. During survey agency obtained an MD order and corrected on site to read PRN. Patent #4: The medication profile indicated that Acetaminophen Suppository was a "crushable" medication. During survey agency obtained an MD order and corrected on site and changed suppository to "non crushable" medication

Upon patient record review, 4 of 14 (Patients #3,8,10,13) 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. Patients #3,8,10,13: These patients bereavement risk assessment were completed late on 11/9/23, not within 5 days of SOC as required.

Upon patient record review, 2 of 14 (Patients #2, 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 medications and treatments. Patient #2: The Plan of Care indicated to administer Acetaminophen 650mg every 4 to 6 hours routine. The hospice eligibility form stated this was PRN not Routine. During survey agency obtained an MD order and corrected on site to read PRN. Patent #4: The Plan of Care indicated that Acetaminophen Suppository was a "crushable" medication. During survey agency obtained an MD order and corrected on site and changed suppository to "non crushable" medication

Upon patient client record review, 11 of 14 (Patient #2,4,5,6,8,9,10,11,12,13,14) 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. Patients #2,4,5,6,8,9,10,11,12,13,14 did not have credentials following clinician's name on benefit form.

Upon SNF/NF contract review, 1 of 1 (Care-One contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. The agency amended this contract during survey and is pending SNF signature on addendum.