Every finding on record at Gentle Touch Palliative & Hospice Care, Inc.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medication profile contains lidocaine topical patch with instruction to apply to skin. There is no defined area of skin allowable for administration. The medication profile also contains albuterol, Symbicort, and Incruse Elliptica inhalers with route by mouth instead of inhalation.

Upon patient record review, 2 of 5 records (Patients #4,#5) 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 4: The initial bereavement assessment is signed and dated 12-19-21. There is no evidence on the form that completion of visit date differed from signature date by clinician and was within the 5 day timeframe regulated. Dates of service were 12-5-21-12-16-21 ending in patient revocation. Patient 5: The initial bereavement assessment is signed and dated 12-19-21. There is no evidence on the form that completion of visit date differed from signature date by clinician and was within the 5 day timeframe regulated. Dates of service were 12-7-21-12-15-21 ending in patient revocation.

Upon patient record review, 1 of 5 records (Patient #1) 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 1: The medication list included in the initial plan of care order signed by the medical director includes dose for Lantus injection of 1 tablet. Medication profile in medical chart separate from plan of care was listed correctly.

Upon patient record review, 2 of 5 records (Patients #4,#5) 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: The discharge summary identified patient in possession of hospital bed. There was no evidence of the bed included in the plan of care. Patient 5: The medical record contained nursing documentation upon admission 12/7/21 and follow up 12/15/21 identifying patient in possession of wheelchair. There was no evidence of the wheelchair included in the plan of care.

Upon patient record review, 1 of 1 applicable record (Patient #4) 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 4: The aide care plan included tasks for aide to obtain vital signs including temperature, pulse, respirations, and blood pressure. There is no evidence of parameters for when aide to notify the RN.

Upon patient record review 1 of 1 applicable record (Patient #4) 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 4: The medical record contained aide visits 12-7-21, 12-10-21, 12-14-21, and 12-16-21 with task of tub/shower marked as completed without specification to type. The assigned task on the aide care plan stated assisted bath- chair.

Upon patient client record review, 1 of 5 records (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 1: The medical record contains a certification of terminal illness identifying verbal order was received 12-18-21 by RN. The medical director signed the CTI 12-16-21.

Upon patient client record review, 5 of 5 records (Patients #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 medical record contains a form identified as MD Narrative Summary signed 12-16-21 prior to initial assessment and start of services. This is a separate form in addition to the Certification of Terminal Illness form containing correct dates aligned with the start of care 12-18-21. Patient 2: The medical record contains a form identified as MD Narrative Summary signed 12-16-21 prior to initial assessment and start of services. This is a separate form in addition to the Certification of Terminal Illness form containing correct dates aligned with the start of care 12-18-21. The medical record contains nursing documentation upon admission identifying patient did not have skin breakdown but also stated wound care was completed with soiled dressing removed, legs cleansed with soap and water, bacitracin applied and covered by ABD pads then secured with kling gauze and ACE bandages. Patient did not have wound and documented wound care was imported via documentation template in error. Patient 3: The medical record contains a form identified as MD Narrative Summary signed 12-18-21 prior to initial assessment and start of services. This is a separate form in addition to the Certification of Terminal Illness form containing correct dates aligned with the start of care 12-23-21. The initial comprehensive nursing assessment is documented with date 12/18/21. Printed schedule and consents for start of care show admission date of 12-23-21. Documentation date validated and corrected on site. Patient 4: The medical record contains a form identified as MD Narrative Summary signed 12-4-21 prior to initial assessment and start of services. This is a separate form in addition to the Certification of Terminal Illness form containing correct dates aligned with the start of care 12-5-21. Patient 5: The medical record contains a form identified as MD Narrative Summary signed 12-6-21 prior to initial assessment and start of services. This is a separate form in addition to the Certification of Terminal Illness form containing correct dates aligned with the start of care 12-7-21.