Every finding on record at Green Hills Hospice Inc

Upon patient record review, 11 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11) did not have evidence the plan of care (POC)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 Patients #1,2,3,4,5,6,7,8,9,10,11: The Initial POC indicated for the MSW/SC visit frequency to "Assess and evaluate within 5 days of SOC, then 1X PRN". This Visit frequency did not contain a baseline frequency based on assessment for the PRN.

Upon patient record review, 3 of 14 (Patients #1,3,5) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The record reflected that this patient had a walker, This item was not included on POC. Corrected on Site. Patient #3: The record reflected that this patient had a wheelchair, This item was not included on POC. Corrected on Site. Patient #5: The record reflected that this patient had a bed, over-bed table, and air mattress. These were not included on the Plan of Care.

Upon client record review, 2 of 14 (Patients #1, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #1: The POC listed Skilled Nursing visit frequency of, 1 X's per week (10/2/24). For Benefit Weeks 10/20/24, 10/27/24 and 11/03/24 there were no visits reflected in the patient record. Patient #4: The POC listed Skilled Nursing visit frequency of, 1 X's per week this week. Then, 2X per week (10/13/24). From 10/30/24 to current date, the Skilled Nurse is visiting 1X per week only.

Upon patient record review 3 of 14 (Patient #2, 5, 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 Patient #2: The POC listed Aide offered, but declined. The Aide visited this patient on 10/26/24. Patient #5: Aide Skilled Nursing visit frequency of, 1 X's per week (10/2/24). There were no visits performed by the Aide during the first benefit week of service. Patient #8: The POC listed Aide offered, but declined. The Aide visited this patient on 10/10/24 and 10/15/24.

Upon patient client record review, 12 of 14 (Patients #1,3,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,3,5,6,7,8,9,10,11,12,13,14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information, Notice of Non Coved Items addendum information or Effective Date of Election.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.