Every finding on record at Five Star Hospice and Palliative Care, LLC

Upon patient record review, 2 of 14 (Patients #3, #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #3, #4: The Election of Benefit form did not have Attending Physician entered in space provided on form. Agency contacted patient/family and updated hospice record with Physician Choice form.

Upon patient record review, 6 of 14 (Patients #1. #2, #3, #4, #5, #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: The Hospice and SNF medication profiles did not match. The SNF did not have Lorazepam 2mg/2mL Q4 hours PRN or Losartan 50 mg QD on their med profile Patient #2: The Hospice and SNF meds did not match. The SNF did not have Lorazepam 2mg/2mL Q4 hours PRN, Morphine 0.25mL Q@ hours PRN, Tylenol Suppository 650 mg Q 4hours PRN or Atropine 1% 3 gtts Q1 hour PRN on their med profile. Patient #3:The Hospice and SNF meds did not match. The SNF did not have Lorazepam 2mg/2mL Q4 hours PRN on their med profile. Patient #4: The record reflected this patient had oxygen. Oxygen was not included on the Medication Profile. Corrected on Site. Patient #5: The record reflected this patient had oxygen. Oxygen was not included on the Medication Profile. Corrected on Site. Patient #6: Polyethylene Glycol order with no diluent Ordered on 11/21/23, Corrected on Site.

Upon patient record review, 3 of 14 (Patients 4, #5, #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 #4: The record reflected this patient had oxygen. Oxygen was not included on the Plan of Care. Corrected on Site. Patient #5: The record reflected this patient had oxygen. Oxygen was not included on the Medication Profile. Plan of Care. Corrected on Site.. Patient #6: Polyethylene Glycol order with no diluent. Ordered on 11/21/23, Corrected on Site.

Upon patient record review, 2 of 14 (Patients #2, #3) 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 #2: This patient had a bedside table. This item was not included on Plan of Care. Corrected on Site. Patient #3: This patient had a bedside table and hospital bed. These items were not included on Plan of Care. Corrected on Site.

Upon patient record review, 1 of 14 (Patients #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #11: The Plan of care indicated the Aide Visit Frequency of 3X's per week and 8 PRN. Plan of care does not indicate patient has the functional or cognitive ability to make PRN choice.

Upon patient record review 1 of 14 (Patient #9) 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 Patient #9: The POC listed Aide visit frequency of 3 X's per week. For first Benefit Week there was only 1 visit on 3/15/24. The visit frequency was not met.

Upon patient record review, 1 of 14 (Patient #5) 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. Patient #5:The CTI has incorrect benefit periods. The patient had discharged in Benefit Period 5. Then, per EMR readmitted again in Benefit Period 5, not BP6. Agency has contacted EMR company and ticket is pending to correct.

Upon patient client record review, 4 of 14 (Patients #3, #4, #8, #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3: The Election of Benefit indicated Effective Date of 4/18/23, Per EMR, Hospice services did not begin until 4/20/23. Patient #4: The Election of Benefit form did not have Attending Physician entered in space provided on form. Agency contacted patient/Family and updated hospice record with Physician Choice form. Patient #8: The Election of Benefit indicated Effective Date of 1/24/24. Per EMR, Hospice services did not begin until 1/25/24. Patient #12: The Election of Benefit indicated Effective Date of 4/28/23. Per EMR, Hospice services did not begin until 4/29/23.

Upon personnel record review, 2 of 13 (Personnel #6, #7 ) did not have evidence the hospice obtained a criminal background check on these contracted individuals who have direct patient care and access to patient records.