Every finding on record at Kiki Health and Hospice Care LLC

Upon patient record review, 2 of 6 (Patient #1, #4) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1- On 04/06/23 the nurse documents the patient is taking Acetaminophen for pain. Orders for Acetaminophen were not updated on the plan of care. Patient #4- The 11/24/22 plan of care includes orders for nursing to educate the patient/caregiver on PEG tube maintenance. The plan of care also includes an order for nursing to monitor the patient's Intraperitoneal Drain (IP drain) and to teach the patient to drain ascites during non SN visits. The orders are not specific for the management of the PEG tube and IP drain.

Upon personnel record review, 1 of 12 (Personnel # 6) did not have evidence in the personnel file that a complete competency assessment was performed by the aide with a patient. Personnel #6-The Aide competency on record 01/06/23 did not evidence the Aide was observed on the following tasks prior to providing care independently: (A) Bed bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination

Upon patient record review, 6 of 6 (Patient #1, #2, #3, #4, #5, #6) did not evidence the agency has a complete election statement in accordance with 418.24. Patient #1, #2, #3, #4, #5, #6-The name of the hospice is not included on the signed elections. A date is in the space designated for the agency name. The records did not contain the updated requirements for the election statement that went into effect on October 2020. Notification of the beneficiary’s right to request in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that includes information and rationale for why the hospice has determined items, drugs, or services unrelated to terminal illness and that immediate advocacy is available through the Beneficiary and Family-Centered Care Quality Organization (BFCCQIO) if the beneficiary disagrees with the Hospice's determination.