Every finding on record at La Hospice

Upon client record review, 1 of 5 (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 Patient admitted 06/14/22. The POC/IDG Review for all documented reviews thru 8/30/22 was "MSW initial evaluation within 5 days". The 6/15/22 MSW Initial assessment narrative concludes with "MSW will continue to monitor patient and provide ongoing psychosocial support on a monthly basis." MSW documented telephone visits 7/15/22 and 8/15/22. However, there was no documented physician order or update POC/IDG Review for MSW planned visit frequency for 1x/mo visits.

Upon personnel record review, 1 of 1 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #6: The skills competency form does not differentiate different types of shampoo. Therefore, unable to confirm competency all sink, tub, bed shampoos.

Upon patient client record review, 1 of 5 (Patient #3) 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 #3: Patient Election Statement space allocated for effective date is blank. There is also a space for effective date of election on Informed Consent and Treatment Authorization Form, that effective date space is also blank.

Upon patient client record review, 2 of 5 (Patients #2, 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. Patients #2, 5: The agency uses combination of paper and electronic medical records. The paper record primarily includes hard copies of admission documents. Both records have POLST forms, marked Do not attempt resuscitation, and both POLST forms are dated with patient's respective SOC date. However, for both patients, the Hospice MD EMRs identify patients as Full Code Status / Attempt CPR. The MD initial CTI includes Full Code. There is no identified documentation of change other than these forms in the paper chart.