Every finding on record at Guiding Hope Healthcare System Inc

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence of the appropriate documentation for release of confidential information. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.

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's 1, 2, 3, 4, 5 did not have evidence of MSW or SC initial assessment. RN components incomplete to meet standard.

Upon patient record review, 1 of 5 (Patient #2) 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 #2: The initial bereavement section of RN form is left blank. There is no separate bereavement assessment form completed by RN. (MSW, SC visits declined by patient.)

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #4: The competency checklist utilized by the agency does not differentiate/confirm competency in sink, tub, and bed, but only states shampoo.

Upon patient client record review, 2 of 5 (Patient #1, 4) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Effective date is left blank, also the patient name is signed on the election statement. The patient has an admitting dx of Alzheimer's Disease. Patient #4: Election statement effective date is left blank. The signature is consistent with date services were started.

Upon patient client record review, 2 of 5 (Patient #3,4) 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 #3: Visit notes Aug. 2, 8, 16, 23 have HA SV marked, but no HA requested, ordered or provided. Patient #4: Patient has (2) DC orders dated 5/31/23 and signed by MD. One has "DC patient from Crosslink Palliative and Hospice Care" and the other says "DC patient from Guiding Hope Hospice". Both have Guiding Hope Header including agency contact info. There is no other reference to Crosslink throughout the record.

Upon client record review, 2 of 5 (Patient #4, 5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #4,5: Patients were live discharges (revocations) 5/31/23. There is no evidence that copies of respective discharge summaries were forwarded to attending MD.

Upon client record review, 2 of 5 (Patient #4,5) did not have evidence that the discharge summary includes all required information. Patients #4,5: Patients were live discharges effective 5/31/23. DC Summaries do not include comprehensive summary of the patient's stay, including treatments, symptoms and pain management.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1: Admission forms had what appeared to be patient's signature. It was the patient's name. The patient's admitting diagnosis is Alzheimer's Disease and he has a history of cranial hemorrhage and surgical repair.