Every finding on record at Pathway Hospice, LLC

Upon patient record review, 3 of 13 (Patient #1,#2,#5,) 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. Patient 1, 2, 5: The medication profile did not contain oxygen. This was corrected on site.

Upon patient record review, 2 of 13 (Patient #5,#12) 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 5 and 12: The medical record did not have evidence of an initial bereavement assessment completed within 5 days.

Upon patient record review, 2 of 13 (Patient #5,#9) 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 5: The medical record did not contain a physicians order for oxygen. Corrected on site. Patient 9: The medical record did not contain a physicians order to access and flush the mediport.

Upon patient record review, 8 of 13 (Patient #1,#2,#3,#5,#6,#7,#8,#9) 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 1: The medical record did not contain DME and supplies on the plan of care the nurse mentioned the patient had a trapeze in use; there was no order. Patient 2: The medical record did not contain DME and supplies on the plan of care; there was no order for a nebulizer machine. Patient 3: The medical record did not contain supplies on the plan of care, there was no evidence of wipes, pull ups and chux. Patient 5: The medical record did not contain DME and supplies on the plan of care; supplies: briefs, wipes, chux, and gloves were items documented on the nurses note dated 4/24/22. Patient 6: The medical record did not contain supplies on the plan of care; supplies: pull ups, barrier cream, wipes, chux, and gloves were items documented on the nurses note dated 3/19/22. Patient 7: The medical record did not contain supplies on the plan of care; supplies: briefs, chux, and gloves were items documented on the nurses note dated 3/18/22. Patient 8: The medical record did not contain supplies on the plan of care; supplies: pull ups, barrier cream, wipes, chux, and gloves were items documented on the nurses note dated 5/2/22. Patient 9: The medical record did not contain supplies on the plan of care; supplies for ostomy and pleurx drain were items documented on the nurses notes consistently throughout the record.

Upon patient record review, 4 of 11 applicable (Patient #1,#2,#8,#12) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1, 2, 8 and 12: The aide care plan contained instructions for partial shower and partial bed bath but did not specify when a partial shower or when a partial bath was to be completed.

Upon patient record review 5 of 11 applicable (Patient #1,#2,#5,#10,#12) 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: order on 4/18/22 for aide visits 7x week. 5 of 7 visits completed the week of 4/18, and 4 of 7 visits completed the week of 5/22. Patient 2: order on 3/3/22 for aide visits 5x week. No evidence that 5 visits were completed the week of 3/3/22. Patient 5: order on 4/22/22 for aide visits 5x week. No evidence that 5 visits were completed the week of 4/22/22. Patient 10: order on 5/4/22 for aide visits to increase to 5x week. No evidence that 5 visits were completed the week of 5/4/22. Patient 12: order on 3/8/22 for aide visits 5x week. No evidence that 5 visits were completed the week of 3/8/22.

Upon patient client record review, 1 of 13 (Patient #9) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #9 election of benefit dated effective 2/16/21 and start of care was 2/16/22.

Upon patient client record review, 1 of 13 (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. Patient 6: The medical record contained duplicate aide visit notes for 3/22/22, 4/14/22, 4/27/22.