Every finding on record at Option Hospice Inc.

Upon personnel record review, 1 of 11 (Personnel #11) did not contain evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation: Personnel #11: record did not contain evidence of the initial Volunteer skills competency assessment.

Upon patient client record review, 5 of 14 (Patient #4, #5, #6, #7, and #9) did not contain 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 #4: LVN clinical progress notes from visits dated 8/6/25, 8/12/25, 8/19/25, 8/27/25 and 9/2/25 were not signed/dated. Patient #5: LVN clinical progress notes from visits dated 8/7/25, 8/14/25, 8/21/25 and 8/28/25 were not signed/dated. RN clinical progress note from visit dated 9/4/25 was not signed/dated. Patient #6: LVN clinical progress notes from visits dated 8/9/25, 8/16/25, 8/23/25, and 8/30/25 were not signed/dated. RN clinical progress notes from visits dated 8/9/25 and 9/6/25 were not signed/dated. Patient #7: LVN clinical progress note from visit dated 9/5/25 was not signed/dated. Patient #9: LVN and RN clinical progress notes from visit dated 9/12/25 were not signed/dated.

Upon patient record review, 1 of 5 (Patient #4) 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 includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 4: The medication profile indicates albuterol 2.5mg 1vial q6hours PRN. The medication order is albuterol 2.5mg inhale 1vial via nebulizer q6hours PRN SOB. The medication profile does not include the route or PRN indication.

Upon patient record review and direct observation during the home visit, 1 of 5 (Patient #2) 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 equipment and supply needs. Patient 2: During the home visit, it was observed that the patient had a wheelchair in the home for management of the terminal illness. The wheelchair did not appear on the patient's plan of care.(corrected onsite)

Upon patient record review 1 of 3 applicable (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 1: The hospice aide plan of care dated 08.10.2022 orders aide visits at 2 x weekly. However, during the week of hospice admission the aide only completed one visit to the patient on 08.12.2022.