Every finding on record at Gk Hospice Care, Inc

Upon patient record review 1 of 11 (Patient #7) 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 #7, MSW initial assessment completed on 5/3/22, patient was admitted on 4/8/22.

Upon patient record review, 4 of 11 (Patient #5,6,8,9) 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 #5 Aide assignment on 8/8/22, 8/29/22, 10/3/22 missing parameters for vital signs and no RN signature on document. Patient #6 No parameters for vital signs on Aide assignment dated 8/18/22, 9/21/22, 11/16/22. No RN signature on 8/18/22. Patient #8 No Parameters for vital signs on Aide assignment dated 1/5/22. Patient #9 No Parameters for vital signs on Aide assignment dated 8/11/22.

Upon patient record review 3 of 11 (Patient #5, 6, 8) 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 #5 No aide frequency order for patient. Aide visits completed on these dates without an order 8/10/22, 8/12/22, 8/15/22, 8/17/22, 8/22/22, 8/24/22, 8/28/22, 8/30/22, 9/4/22. 9/6/22, 9/12/22, 9/14/22, 9/25/22, 9/27/22, 10/2/22. 10/4/22, 10/9/22, 10/11/22, 10/16/22, 10/18/22, 10/23/22, 10/25/22. Patient #6 Patient assignment states to change linen every visit, on 12/18/22 linen change was not completed. Patient #8 Frequency order 1x/week. Aide visits on 8/28/22 and 8/30/22, 2x in one week.

Upon patient client record review, 1 of 11 (Patient #11) 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 #11, Missing RN signature on discharge with cause on 10/17/22.

Upon client record review, 2 of 11 (Patient #10,11) did not have evidence that the discharge summary includes all required information. Patient #10, No information on discharge summary except for patient expired 10/20/22 at 11:50pm. Patient #11, Incomplete discharge summary, missing patient's stay, including treatments, symptoms and pain management.