Every finding on record at Halos Palliative and Hospice Care

Upon patient record review 6 of 11 (Patients #1, #3, #4, #5, #7, #11) 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. Patients #1, 3, 4, 5, 7, 11: No evidence of a comprehensive spiritual assessment being completed.

Upon patient record review, 3 of 11 (Patients #5, #7, #10) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: Medication profile listed lactobacillus acidophilus 1 packet po 3 x daily. No diluent or administration instructions listed. Patient #7: Medication profile listed lidocaine patch topical daily. No location listed. Patient #10: Patient documentation indicates patient was on oxygen. Oxygen not listed on the medication list on the plan of care.

Upon patient record review, 1 of 11 (Patient #10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #10: Patient records indicate patient was a DNR. Code status on POC left blank.

Upon patient record review, 1 of 11 (Patient #10) 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 #10: Patient documentation indicates patient was on oxygen. No evidence of an order for Oxygen.

Upon patient record review, 1 of 11 (Patient #10) 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 #10: No DME listed on the POC. Patient had oxygen.

Upon client record review, 4 of 11 (Patients #6, #8, #10, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: MSW ordered 1 x month. No evidence to support a visit was made in July. Patient #8: RN ordered 1 x wk on POC. 2 visits were made the week of 6/19, 6/26 and 7/4. No evidence of PRN visit or orders to increase visit frequency. Patient #10: SN ordered 1 x wk on POC. 2 visits were made the week of 2/20/2022. No evidence of PRN visit or orders to increase visit frequency. Patient #11: MSW ordered 1 x wk on the POC. No evidence to support a visit was made the week of 1/26/2022.

Upon patient client record review, 4 of 11 (Patients #1, #2, #4, #8) 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 Patients #1, 2, 4, 8: Hospice Election form missing the effective date and patient date that form was signed.

Upon patient client record review, 1 of 11 (Patient #1) 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: Agency forms for mortuary agreement, oxygen safety, patient acknowledgment and notice of information received were incomplete and not dated by patient when signed.