Every finding on record at Optimal Cares, LLC

Upon patient record review 1 of 11 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: The SOC date was 4/21/2023. SC assessment done 5/1/2023. MSW completed 5/5/2023. There was no evidence of a comprehensive assessment within 5 days.

Upon patient record review, 5 of 11 (Patient #6, #8, #9, #10, #11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review should be included with the initial comprehensive assessment and should be ongoing throughout the episode of care. Patient #6: There was no evidence of the O2 order dated 4/20/2023 O2 2-5 L via NC PRN for Shortness of breath or mental status changes on the Medication Profile. On Medication Profile for Miralax dated 4/20/2023 included Miralax 17GM/scoop, admin 17GM by mouth PRN for constipation. There was no evidence of a frequency of the PRN or diluent. Patient #8: There was no evidence of the O2 order dated 3/24/2023 O2 2-5 L via NC PRN for Shortness of breath or mental status changes on the Medication Profile. Patient #9: There was no evidence of the O2 order dated 2/28/2023 O2 2-5 L via NC PRN for Shortness of breath or mental status changes on the Medication Profile. Patient #10: There was no evidence of the O2 order dated 2/24/2023 O2 2-5 L via NC PRN for Shortness of breath or mental status changes on the Medication Profile. Patient #11: There was no evidence of the O2 order dated 2/28/2023 O2 2-5 L via NC PRN for Shortness of breath or mental status changes on the Medication Profile

Upon patient record review, 1 of 11 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: SOC 4/21/2023. Bereavement assessment occurred 5/5/2023. There was no evidence of bereavement in the comprehensive assessment within 5 days.

Upon patient record review, 1 of 11 (Patient #6) 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 6: An order for Miralax dated 4/20/2023 included Miralax 17GM/scoop, admin 17GM by mouth PRN for constipation. There was no evidence of a frequency of the PRN or diluent.

Upon client record review, 1 of 11 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: Orders on POC dated 5/31/2023 include MSW 1 x month. There was no evidence of a MSW visit or missed visit for the month of June. The POC dated 6/14/2023 included order for Vol. weekly. There were no Vol. visits weeks of 6/18/23, 6/25/23, 7/2/23 and 7/9/2023.

Upon patient record review, 6 of 11 (Patient #1, #2, #3, #5, #7, #9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #1: Pt. has history of Seizures, and SOC assessment identified fall risk. The POC included Seizure and fall precautions. The HHA assignment showed no evidence of seizure or fall precautions. HHA assignment corrected going forward on site. Patient #2: Pt. has history of seizures, history falls, and identified as fall risk on SOC assessment. an order exists for O2. The POC includes fall precautions, evaluation for seizure and O2 use. HHA assessment has no evidence of seizure precautions, fall precautions or O2 precautions. HHA assignment corrected going forward on site. Patient #3, 5, 7, 9- Pt. had order for O2, identified as fall risk on SOC assessment. The POC included O2 use and fall risk precautions. The HHA assignment has no evidence of O2 or fall precautions.

Upon personnel record review, 1 of 11 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements Employee #2: There was no evidence the Alt. Admin met the appropriate education requirements for the role.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes when the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director.There was no evidence of a physician designee. Corrected on site.