Every finding on record at Medical Alliance Group

Upon patient client record review, 4 of 14 (Patient #5,8,9,11) 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. #5,8,9,11-Clinician signature on consent form was not legible.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence of the appropriate documentation for release of confidential information. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient record review 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1,2,3,4,5: Missing spiritual assessment within first 5 days. This assessment was not completed during RN assessment, documentation states patient needs spiritual care. Spiritual Care documented patient refused visit. No assessment completed.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, LVN used hand sanitizer to wash hands then went into bag to remove thermometer placed on chux, went back into back to grab additional items without sanitizing hands every time LVN went into nursing bag. LVN used gloves to remove items from nursing bag and forgot to sanitize hands after removing gloves. Patient #2, LVN used hand sanitizer to wash hands then went into bag to remove thermometer placed on chux, went back into back to grab additional items without sanitizing hands every time LVN went into nursing bag. Patient #3, LVN used hand sanitizer to wash hands then went into bag to remove thermometer placed on chux, went back into back to grab additional items without sanitizing hands every time LVN went into nursing bag. LVN used gloves to remove items from nursing bag and forgot to sanitize hands after removing gloves.

Upon personnel record review, 1 of 1 applicable(Personnel #6) did not have evidence in the personnel file that the competency assessment of the aide included all required elements. ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, rectal and digital. ·Toileting and elimination

Upon patient record review 1 of 1 applicable (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #4, Care Plan did not identify HHA to make bed and HHA documented making bed was completed on 8/12/21, 8/19/21, 8/26/21, 9/2/21, 9/9/21, 9/16/21, 9/23/21, 9/30/21, 10/7/21, 10/14/21, 10/21/21, 10/28/21.

Upon personnel record review, 12 of 12 (Personnel #1,2,3,4,5,6,7,8,9,10,11,12 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains Advance Directives Patient #3, Wrong patient name on admission paperwork, however, admission paperwork signed by appropriate caregiver.

Upon patient client record review, 4 of 5 (Patient #3) 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. Patient #1, missing date of signature on RN assessment for 4/14/22 and 7/7/22. Patient #2, missing dates with signatures on IDG notes 3/4/22, 3/18/22, 4/1/22, 4/15/22, 4/29/22, 5/13/22, 5/27/22, 6/24/22, 7/8/22. RN assessment on 3/4/22 had no date with signature. Patient #3, missing date with signature on 6/24/22, 7/8/22. Patient #4, missing date with signature on MSW assessment on 8/13/21. Missing date with signature on hospice medication sheet. Missing dates with signatures on IDG notes on 8/12/21, 8/19/21, 8/26/21, 9/9/21, 9/16/21, 9/23/21, 9/30/21, 10/7/21, 10/14/21, 10/21/21, 1028/21.

Upon client record review, 2 of 2 (Patient #4,5) did not have evidence that the discharge summary includes all required information. Patient #4, Discharge summary states in summary 'treatments, vital signs completed.' Missing evidence of a summary of the patient's stay including treatments, symptoms, and pain management. Patient #5, Discharge summary was blank for paragraph to explain summary of care.

Upon patient record review, 3 of 5 (Patient #2, 3, & 5) as observed during home visit, did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs of the following patients were not included in the plan of care as follows. Patient #2 was observed to have a walker. Walker was not included in the plan of care. Patient #3 was observed to have a cane, walker and wheelchair. These items were not included in the plan of care. Patient #5 was observed to have a cane. A cane was not included in the plan of care.

Condition of Participation: Infection Control.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence documented that the Board of Directors/governing body reviewed and approved the adopted COVID 19 polices of the agency. This agency's Policy Manual states that all policies, and new policies will be reviewed and approved by the governing body. There was no document evidence of an approval by governing body. In addition, the governing body/administrator did not ensure that all employees and contracted employees who provided care directly were fully vaccinated against COVID 19 or had an approved exemption.

Upon client record review, 1 of 1 applicable (Patient #1) the discharge summary was not faxed to the patient's attending physician.

As observed and upon review there was no process implemented to ensure the additional precautions intended to mitigate the transmission and spread of COVID–19, for all personnel who are not fully vaccinated for COVID–19. The agency Covid Policy states that agency will provide accommodations and contingency plans for unvaccinated staff including those with exemptions and will adhere to additional precautions to support risk reduction of Covid -19 transmission. There were 2 staff that had religious exemptions and 1 that was unvaccinated. There was no accommodations or any contingency plan actions implemented for these staff.