Every finding on record at First Unlimited Hospice Care, Inc.

Upon patient record review 1 of 14 (Patient #2) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #2: There is evidence in the record that the Start of Care on the signed Election of Benefits was 10/26/23. The initial RN assessment was completed on 11/26/23.

Upon patient record review 1 of 14 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2: There is evidence in the record that the Start of Care on the signed Election of Benefits was 10/26/23. The nursing comprehensive assessment was completed on 11/26/23. The comprehensive assessment was not completed within 5 days.

Upon patient record review, 4 of 14 (Patient #3,4,6,10) 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 #3: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the medication profile. Patient #4: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the medication profile. Patient #6: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the medication profile. Additionally, the order O2 2L/min per NC for SOB, may titrate 3L/min to 5L/min as needed for SOB. The order did not contain parameters for titration. Patient #10: There was evidence in the record of Bactrim DS for 7 days. There was no stop date on the medication record.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: There is evidence in the record that the Start of Care on the signed Election of Benefits was 10/26/23. The bereavement assessment was not completed.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the Plan of Care as a medication. Additionally, the patient was admitted with Hypertensive Heart Failure and had edema related to a DVT. The plan of care did not include Cardiovascular problem.

Upon patient record review, 5 of 14 (Patient #3,4,6,9,10) 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 #3: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the Plan of Care as a medication. Patient #4: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the Plan of Care as a medication. Patient #6: There was evidence in the patient record for Oxygen ordered as a treatment. Oxygen was not listed on the plan of care as a medication. Patient #9: There was evidence in the nurses' note "patient has a PEG tube". There was no order for the PEG tube. Patient #10: There was evidence in the record of Bactrim DS for 7 days. There was no stop date for the medication on the plan of care.

Upon patient record review 1 of 14 (Patient #1) 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 #1: There is evidence in the medical record that the aide frequency is 2 visits/wk. The week of 7/14/24, the aide visited the patient 3 times/wk.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body minutes did not reflect Quality Assessment/Performance Improvement. (corrected on site.)

Upon patient record review, 1 of 14 (Patient #2) 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 Patient #2: There is evidence in the record that the Election of Benefits indicated a start date of 10/26/23. The Verbal Certification of Terminal Illness was not received until 11/26/23

Upon patient client record review, 6 of 14 (Patient #2,3,4,5,6,10) 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 #2: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services. Additionally the Start of Care date was blank on the EOB. Patient #3: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services. Patient #4: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services. Patient #5: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services. Patient #6: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services. Patient #10: There is evidence in the record that the Election of Benefits did not contain information regarding availability of the QIO. Additionally, the EOB did not contain information regarding the opportunity to request a list of non-covered items/services.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: The signed Election of Benefits has a start of care date 8/29/23. The Admission Agreement lists the start of care date 9/1/23. There was confusion between the two documents.