Every finding on record at Gentle Haloes Hospice

Upon patient record review 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual 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. Patient #1: There is no evidence in the record of a spiritual assessment was completed on admission. In addition, there is no evidence in the record of a psychosocial assessment on admission. Patient #2: There is no evidence in the record of a psychosocial assessment was completed on admission. Patient #3: There is no evidence in the record of a psychosocial assessment was completed on admission. Patient #4: There is no evidence in the record of a psychosocial assessment was completed on admission. Patient #5:There is no evidence in the record of a spiritual assessment was completed on admission. In addition, there is no evidence in the record of a psychosocial assessment on admission.

Upon patient record review and, 4 of 5 (Patient #1, #2, #3, #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 #1: The Plan of Care indicates all medications including Levothyroxine, Methocarbamol, etc. did not have a start date. Patient #2: The Plan of Care indicates all medications including Losartan, Xarelto, etc. did not have a start date. Also,upon home visit, the agency medication record did not list Amlodipine, Pregabalin, Atorvastatin, Celebrex, etc., that the patient was currently taking at home. Patient #3: The Plan of Care indicates all medications including Duloxetine, Levothyroxine, etc. did not have a start date. Also, upon home visit, the agency medication record did not list Atorvastatin that the patient was currently taking at hom Patient #4: The Plan of Care indicates all medications including Atorvastatin, Metformin, etc. did not have a start date.

Upon patient record review 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3: There is evidence in the record of a RNCM IDG note 6/9/24 "she and her husband would like MSW visit about advanced directives". There is no evidence of MSW visit.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, #5) 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: The Election of Benefits staff signature is illegible and is incomplete without credentials. Patient #2: The Election of Benefits staff signature is illegible and is incomplete without credentials. Patient #3: The Election of Benefits staff signature is illegible and is incomplete without credentials. Patient #4: The Election of Benefits staff signature is illegible and is incomplete without credentials. Patient #5: The Election of Benefits staff signature is illegible and is incomplete without credentials.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: There is evidence in the patient record that the discharge summary did not include a summary of the patient's stay, including treatments, symptoms and pain management.