Every finding on record at Idt Hospice Care Inc

Upon patient record review 1 of 14 records reviewed (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4: The patient was admitted on 10/26/24. The psychosocial comprehensive assessment was not completed until 11/08/24.

Upon patient record review, 3 of 14 records reviewed (Patient #3, #5, #6) 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 #3: The medication profile had Hydrocortisone 1% thin film topical BID for rash/itch. There was no site location listed. COS Patient #5: The medication profile had Diclofenac gel 1% thin layer topical TID for pain. There was no site location listed. COS. Patient #6: The medication profile had Tylenol Suppository 650mg PR Q4hours prn and Tylenol 500mg 2 tabs po Q6hours prn pain, discomfort, fever of 100.1 or above. No indication listed not to exceed 4 grams in a 24 hour period. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #4) 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 #4: The patient was admitted on 10/26/24. The bereavement assessment was not completed until 11/08/24.

Upon patient record review, 2 of 14 records reviewed (Patient #4, #6) 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 #4: The patient was admitted on 10/26/24 with a full code status. There was no individualized written plan of care that reflected patient/family goals and interventions based on this problem. COS. Patient #6: The patient was admitted on 04/04/24 with a full code status. There was no individualized written plan of care that reflected patient/family goals and interventions based on this problem. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #4) did not have evidence the plan of care 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 • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4: The record indicated on 10/26/24 the RN visits were ordered as needed and on recertifications. There was no evidence of a routine frequency. COS.

Upon patient record review, 3 of 14 records reviewed (Patient #3, #5, #6) 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 #3: The orders had Hydrocortisone 1% thin film topical BID for rash/itch. There was no site location listed in the order. COS Patient #5: The orders had Diclofenac gel 1% thin layer topical TID for pain. There was no site location listed in the order. COS. Patient #6: The orders had Tylenol Suppository 650mg PR Q4hours prn and Tylenol 500mg 2 tabs po Q6hours prn pain, discomfort, fever of 100.1 or above. No indication listed not to exceed 4 grams in a 24 hour period. COS.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The record indicated on 01/03/24 the IDT ordered MSW x1 within 5 days of admission, the patient was admitted to hospice on 10/17/24, this is an incorrect order. SW called patient on 1/13/25 and made a visit on 1/20/25 with no order. COS.

Upon client record review, 1 of 8 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 has visit frequency for SN 1x/week, Patient has SN visits on 1/26/22 and 1/27/22.

Upon patient record review 3 of 3 applicable (Patient #3, 4, and 6) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patients 3 and 4 both had snack documented on care plan for Aide to complete, neither patient had task completed. Patient #6 has order for HHA 2x/week on 10/13/21, services started on 11/5/21 with only 1 visit that week.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Upon chart review, Patient #4 paperwork of order for admit to hospice with diagnosis filed in patient #3 file.