Every finding on record at Mountainside Hospice and Palliative Care, Inc.

Upon patient record review, 9 of 14 (Patient #1, #2, #3, #5, #6, #7, #8, #9, #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1-3, 5-10: Records indicate no evidence of Patient/Caregiver signing Change of Attending Form upon Hospice Agency, Medical Director resigning from Agency effective 2/24 and each election of benefit form listed this physician specifically.

Upon patient record review, 3 of 14 (Patient #5, #7, #8) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #5; Records indicate evidence of active symptoms with no documentation of follow up with RN or Hospice Physician and no interventions completed upon LVN visit performed on 12/29/23, patient reports chest pain episodes poorly relieved with nitroglycerin. Additional complaints from patient of chest pain persists on 4/11/24 with no follow up with RN or Hospice Physician and no documented interventions completed. Patient #7: Records indicate evidence of RN and LVN documentation on every visit completed for first and second benefit period of patient reports shortness of breath at rest. LVN has no documentation of reporting active dyspnea to RN or MD notification, evidence of sob with minimal relief with ordered medication therapy in place. RN visits have no evidence of MD notification despite continued patient reports of dyspnea with active medication regime. Education provided by RN/LPN in each visit is the repeated of deep breathing techniques, energy conservation and low sodium diet. No evidence of changes to plan of care or or higher level of care to manage uncontrolled symptom. Patient #8: Records indicate patient complaints of continued chest pain per RN assessment on 5/2/24 with no MD notification or changes to plan of care. In addition, LVN visit on 5/9/24 documentation states patient continues to report chest pain poorly relieved by ordered nitroglycerin with no evidence of updating RN or MD notification to uncover if medical intervention or need for higher level of care, is ordered to effectively manage active symptoms of chest pain.

Upon patient record review, 2 of 14 (Patient #1 and #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Records indicate on medication profile per Physician order of Oxygen 2L via NC, PRN. RN visit on 2/26/24 and LVN visit on 2/29/24, patient is administering 3L of Oxygen to manage dyspnea and there was not an update to the order on file. Patient #3: records indicate no evidence of medications listed on Initial Plan of Care on 12/07/23.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: Records indicate no evidence reason Physician ordered antibiotic Doxycycline Monohydrate 7mg PO 1 capsule three times daily X 10 days verbal order on 3/21/24 with no update to the plan of care regarding infection.

Upon patient client record review, 1 of 14 (Patient #6) 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 #6: Records indicate no evidence of chaplain signature or date on Initial Spiritual Care Assessment on EMR date, 2/05/24.