Every finding on record at Millenia LLC

Upon patient record review 1 of 3 applicable (Patient #2) 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 #2 - Aide ordered 2xwk on initial plan of care. Week of 12/14/2022 only 1 aide visit was provided on 12/16/2021. No evidence to support an order for a change in frequency or missed visit documentation.

Upon patient client record review, 1 of 7 (Patient #5) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #5 - The hospice name on the Election of Benefits had been written over and was illegible.

Upon patient client record review, 3 of 7 (Patient #1, #2, #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 - CTI episode end date was noted to be an error. It was listed as 2/16/2021 instead of 2/16/2022 Patient #2 - Election of Benefits noted to have incorrect episode end date of 3/13/2021 instead of 3/13/2022. CTI end of episode date was noted to be in error. It was listed as 3/13/2021 instead of 3/13/2022 Patient #3 - CTI episode end date was noted to be an error. It was listed as 3/4/2021 instead of 3/4/2022.

Upon client record review, 1 of 1 applicable (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: SN ordered 2xwk on the initial plan of care. The week of 1/2/2022 and the week of 1/16/2022 only one visit was performed each week. No evidence to support an ordered change in frequency or missed visit documentation.