Every finding on record at Hospice of the East and Palliative Care Inc

Upon patient record review, 3 of 6 (Patient #1,#2,#3) 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 #1: There is evidence that the patient is no longer using triamcinolone cream. The medication remained on the medication profile. Patients #1,#2,#3: There is documentation that the patient was using oxygen. Oxygen therapy was not included on the medication profile.

Upon patient record review, 1 of 6 (Patient #2) 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 #2: There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the integumentary aspect of the patient. The update to the comprehensive nursing assessment dated 10/10/22 identified redness to the coccyx and bilateral buttocks.

Upon patient record review, 3 of 6 (Patient #1,#2,#3) 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. Patients #1,#2,#3: The record indicated that the patients had oxygen via nasal cannula. There was no evidence of an update to the plan of care to include oxygen therapy.

Upon patient client record review, 2 of 6 (Patient #1,#5) 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: The Hospice Medicare Election statement was dated effective on 11/8/2021. The episode dates on the certification of terminal illness reflects 11/9/21-1/7/22. The dates of the hospice certification period do not reflect the effective date that was elected by the beneficiary. Patient #5: The Medicare Election statement was dated 9/2/21 with an effective date of 9/1/21.

Upon patient client record review, 3 of 6 (Patient #4,#5,#6) 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 #4: The subsequent updates to the plan of care included a summary by the MSW but were not appropriately authenticated. There was no evidence of a signature by the MSW on the subsequent updates to the plan of care for dates 9/13/21, 9/27/21, 10/11/21,10/25/21, and 10/31/21. The IDG summary/update to the plan of care dated 10/31/21 indicated the patient was given 14 days notice for discharge due to extended prognosis. The discharge summary dated 10/31/21 indicated the patient was discharged due to seeking treatment at the hospital for pneumonia. The administrator confirmed the patient revoked due to refusing hospice services to seek treatment at the hospital for pneumonia. Patient #5: The subsequent updates to the plan of care included a summary by the MSW that were not appropriately authenticated. There was no evidence of a signature by the MSW included on the subsequent updates to the plan of care for dates 9/13/21, 9/27/21, 10/11/21, 10/25/21, and 10/31/21. The IDG summary/update to the plan of care dated 10/31/21 indicated the patient was given 14 days notice for discharge due to extended prognosis. The discharge summary dated 10/31/21 indicated the patient was discharged due to revoking hospice due to the increase in COVID 19 cases. The administrator confirmed the patient revoked due to refusing hospice services due to the increase in COVID 19 cases. Patient #6: The subsequent updates to the plan of care included a summary by the MSW that were not appropriately authenticated. There was no evidence of a signature by the MSW included on the subsequent updates to the plan of care for dates, 1/15/21,11/29, 12/13, 12/27 , 1/10/22, 1/24, 1/28.