Every finding on record at Grace Hospice and Palliative Care, LLC

Upon patient record review, 3 of 5 (Patient #1, #3, #5) did not have evidence that the patient's choice of health care provider was honored. Patient #1, #5- The Hospice election notice indicates the patient chose the NP as the attending; however the initial plan of care was sent to the Alternate Medical Director for signature. Patient #3-The Hospice election notice indicates the patient chose the Med Director as the attending; however the initial plan of care was sent to the Alternate Medical Director for signature.

Upon patient record review, 2 of 4 applicable (Patient #1, #2) did not have evidence in the patient record that the hospice conducted and documented in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, including a complete spiritual assessment. Patient #1-The patient refused Chaplain services on 01/06/22. A complete spiritual assessment was not performed by the RN or Social Worker. The only documentation regarding spiritual needs is that the patient is Christian and beliefs have been disrupted by disease process in the initial nursing assessment. Patient #2- The patient refused Chaplain services. A spiritual assessment was not performed by the RN or SW.

Upon patient record review, 2 of 5 (Patient #1, #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. Patient #1-On 02/02/22 the nurse documents the patient was prescribed Fosfomycin 3 gm packet q72 h x3 doses for a UTI. Fosfomycin was not updated on medication profile. Patient #4-On 11/09/21 the nurse received orders for MS04 10 mg po q4h prn pain, Ativan .5 mg q4h prn anxiety and Tylenol 650 mg po q6h prn fever- not to exceed 3000 mg a day. The medication profile was not updated with the medications . The patient was admitted on Oxygen and Oxygen is not on the med profile.

Upon patient record review, 2 of 5 (Patient #1, #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1- The 01/05/22 plan of care does not include interventions for Aide services Patient #4-The 11/05/21 plan of care does not include the frequency for nursing , social worker, spiritual care or aide. The plan of care does not include interventions for social worker, spiritual care, or Aide services

Upon patient record review, 2 of 5 (Patient #3, #4) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #4- The 11/05/21 plan of care reads RN to provide wound care weekly to coccyx wound until healed. The orders are not specific for the actual wound care/dressing change to be performed. The plan of care includes 02 at 4lpm per nc. The orders do not specify whether the Oxygen is prn or continuous. Patient #5-The plan of care 01/06/22 includes orders to provide wound care to the left lateral heel as ordered. The orders are not specific for the actual wound care to be performed. Orders also include change urinary drainage device as ordered. The orders are not specific for the Foley size/balloon size, maintenance and/or changes. On 12/24/21 the nurse documented the patient was to start ice therapy to left foot three times daily for 15 minutes for swelling. The order for ice therapy was not updated on the plan of care.

Upon patient record review, 3 of 5 (Patient #1, #2, #3 ) did not evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and included in the plan of care. Patient #1- The Aide is assigned to perform linen change and make bed every visit. On 02/03/22 the aide did not document the tasks were performed. Patient #2- The Aide is assigned to document the patients last bowel movement every visit. The last BM was not documented on visit notes 12/28/21, 01/17/22 and 01/28/22. Patient #3-The Aide is assigned to document the patients last bowel movement every visit. The last BM was not documented on 02/07/22.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence that all entries are complete, accurate and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1 The Aide visit notes 01/25/22, 01/28/22 , 01/31/22 and 02/03/22 do not include employee credentials. Patient #2- The Aide visit notes on record 12/03/21-01/21/22 do not include credentials. On 12/21/21 and 12/24/21 the nurse documented performing wound care. The documentation is not specific for the actual wound care performed. Patient #3- Aide credentials are not on the 02/07/22 visit note. Patient #4-The CTI on record is not dated with the physician electronic signature. Aide credentials are not on the visit notes. Patient #5- On 12/10/21 the nurse documents in IDG that the patient is 93 years old. The correct age of the patient is 88. Aide visits 12/09/21-01/31/22 do not include credentials. (corrected on site)