Every finding on record at Noble Care Services West LLC

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Election statement section for 'Right to Choose a Physician' was left blank. There was not evidence in the record of the patient choosing an attending physician.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #2, received Chaplain visits on 10/13/2021, 10/28/2021and 11/17/2021, however, there was no Chaplain Services ordered by the Physician.

Upon patient record review 4 of 5 (Patients #1, #2, #3 and #5) did not have evidence documentation in the patient record that the hospice aide provided services that were ordered by the IDG and included in the plan of care. Patient #1- On the visits conducted on 10/22/2021 and 11/11/2021, the Aide failed to provide foot care, oral care, nail care and linen change as assigned by the RN. On 11/16/2021, the Aide failed to provide foot care, oral care, nail care and take vital signs as assigned by the RN. Patient #2- On 10/14/2021, the Aide failed to provide a shower and take vital signs as assigned by the RN. On 10/28/2021, the Aide failed to provide linen change, foot care, nail care and shower as assigned by the RN. On 11/10/2021, the Aide failed to provide foot care and nail care as assigned by the RN. Patient #3-On 10/20/2021, the Aide failed to provide oral care and nail care as assigned by the RN. On 11/17/2021, the Aide failed to provide oral care, shampoo, shower and take vital signs as assigned by the RN. Patient #5-On 8/13/2021 and 9/10/2021, the Aide failed to provide a shower as assigned by the RN.

Upon patient record review 1 of 5 (Patients #1) did not have evidence in the patient record that the hospice aides report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. Patient #1- On 11/17/2021, the Aide documented ..."withdrawn and negative during the entire visit saying, I'm so afraid of myself. I asked [Name] if she planned to hurt herself and she said I wouldn't even know how and my religion wouldn't allow it..." There was no documentation to indicate the Aide informed the RN.

Upon patient client record review, 2 of 5 (Patients #1 and #4) did not have evidence that each patient record contained a signed election statement in accordance with 418.24. Patients #1: Election statement did not include an effective date of the election nor did it include the patient's choice of attending physician. Patient #4: Election statement did not include the effective date of election.

Upon patient client record review, 5 of 5 (Patients #1, #2, #3, #4 and #5) 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. Patients #1-#5: Based on the Initial Bereavement Assessment, the Bereaved had been assigned as a"low risk, however, the questions on the Bereavement Assessment had not been completed. Based on the Agency's Policy Documentation Requirements (PC.D25) no spaces are left blank on documentation tools and forms. Patient #3: A face to face was performed by the Medical Director on 6/21/2021. There was no signature on the Face to Face. Based on the Agency's Policy Documentation Requirements" (PC.D25), all documentation is signed using complete first and last name, credentials and title.