Every finding on record at Hh and Ll Hospice Care Inc

Upon patient record review 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 1 comprehensive assessment and plan of care included O2 @ 2-5 LPM via nasal cannula continuously and hospital bed. There was no evidence of oxygen or a hospital bed in the home during home visit.

Upon personnel record review, 2 of 12 (Personnel # 3, 7) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel 3 and 7 had no evidence of dated and signed withholding statements.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency was not providing core services as evidence by personnel 3 and 7 had no evidence of dated and signed withholding statements. Personnel were providing care and performing visits on behalf of the agency.

Upon patient client record review, 2 of 14 (Patient 1 and 5) 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 IDG meeting minutes conducted on 7/30/24 and 7/16/24 had evidence of attendance by MD, SN, SCP and MSW but no evidence of discipline signatures and dates from MD and SN. Patient 5 IDG meeting minutes conducted on 07/02/24 had evidence of attendance by MD, SN, SCP and MSW but no evidence of discipline signature and dates from MD and SN.