Every finding on record at Medallion Hospice Care Inc

Upon patient record review, 7 of 14 (Patient #1,5,6,7,11,12,14) 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 #1, 5, 6, 7, 11, 12, 14: Initial bereavement by MSW states bereavement process has been initiated.... However, it is not clear who the bereaved person is or what the relationship is to patient.

Upon personnel record review, 1 of 12 (Personnel #5) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: The competency form utilized by agency validates shampoo, but not specifically sink, tub, bed.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Primary Dx Atherosclerotic Heart Disease of Native Coronary Artery without Angina. Notice of Non-Covered Items Addendum list no unrelated diagnoses, but shows Ozempic and Metformin as not covered by hospice.

Upon patient record review, 2 of 14 (Patient #7, 8) 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 #7: Physician initial CTI narrative says "SOB with oxygen dependency". There is no order for Oxygen and there is no Oxygen addressed in IDG POC. Comprehensive marked none for Oxygen. Upon interview, the nurse reports patient refused Oxygen. Was not reflected in documentation. Pt #8: Patient admitted with Dx Senile Degeneration of Brain. Consents signed by daughter. DNR dated 9/2/24 identifies signature as self, although, staff reports the signature is that of daughter.

Upon patient record review, 2 of 12 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patient #11, 12: The discharge summaries do not include clinical summary of care such as treatments, symptoms and symptom management, the POC or physician orders. They simply state discharged due to revocation with no other details, other than notifications and copies sent.