Every finding on record at Montrose Hospice, Inc

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.) (C) Shampoo, sink, tub, and bed Personnel #5: The HA competency form utilized by the hospice lists shampoo as task for demonstrated competency and does not specify types of shampoo sink, tub, bed.

Upon patient record review, 1 of 9 (Patient #9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #9: CTI Benefit period #5 from 3/15-5/13/24 was signed 4/12/24 with no documented verbal certification received.

Upon patient client record review, 1 of 14 (Patient #6) 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 #6: There is a 3/4/24 Physician order to refer patient to Wound Pro for wound consultation. There is no documentation specifying whether or not wound is related to the primary diagnosis of Alzheimer's. Also, this patient transferred to hospice 3/4/24 in 11th benefit period and requested Notice of non-covered items addendum however, there was no evidence this was delivered to the patient.

Upon patient client record review, 2 of 14 (Patient #1, #12) 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 #1: 5/20/24 SN visit note. Per pcg/family patient didn't have bowel movement since 5/14/24 enema was given til the end of the visit patient didn't have bowel movement will wait. 5/28/24 note per son patient didn't have bowel movement for 3 days now informed son will administered Bisacodyl suppository but refused and said wife ... will administer later at night. Documentation for both dates is unclear as to who will wait or administer as well as patient status, interventions and outcomes. Patient #12: Discharge summary did not include all required information. Patient death certificate and information inadvertently added to patient's record/discharge summary. A copy of the death certificate was sent and the post death bereavement services provided were communicated to the PCP. Interview with staff clarifies the patient revoked and did not pass away.