Every finding on record at Perfect Care Hospice, Inc.

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #7: MSW making visit was wearing picture ID badge from a different hospice provider, stating she left her Perfect Care Hospice ID badge at home.

Upon client record review, 7 of 15 (Patient #1,2,3,4,5,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 1/2/24. MSW frequency per IDG 1/10/24 and forward: MSW 1/wk and 3 prn-initial assessment, recertification once a month 2 prn visits emotional support as needed. Visits were provided monthly. SC frequency per IDG 1/10/24 and forward is SC 1/mo and 2 prn . No SC visit documented for March. Patient #2: SOC 1/2/24. SC frequency per IDG POC is 1/month and 2 PRN. There is no documented visit for March. Patient #3: SOC 1/12/24. Same date order to report SBP over 160 and DBP over 90. 3/27 visit documented BP 165/112 at beginning of visit and 150/98 at end of visit. No evidence it was reported. 3/22/24 visit documented patient reported BP had been in 200s. No evidence it was reported. Patient #4: SOC 1/20/24. MSW frequency per IDG POC is 1/month and 2 prn. There is no MSW visit documented for March Patient #5: SOC 2/1/24. MSW frequency per IDG POC is 1/month and 2 prn. There is no MSW visit documented for March Patient #10: SOC 12/24/23. SC frequency 1/month and 2 prn. No documented visit for March Patient #11: SOC 12/20/23. SC frequency 1/month and 2 prn. No documented visit for March.

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #5: There was no documented evidence that aide's initial competency was completed in all (3) types of shampoo were observed and confirmed.

Upon patient client record review, 2 of 15 (Patient #1,13) 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 #1: SOC 1/2/24. Nursing entry 1/10/24 IDG: 1/03/24 Bereavement coordinator called and reported that the initial assessment was done today. Hospice MD notified and obtained new order. Discontinue Bereavement Coordinator for initial assessment to provide bereavement counseling and support. Start bereavement coordinator. Will complete all bereavement follow up assessment post death. (The bereavement assessment is documented by SC as occurring 1/4/24 with Tony, caregiver and signed and time stamped.) Patient #13: SOC identified in EMR as 11/9/22. Noted uploaded consent and hospice election forms have signature dates that have been altered with white out. 11/9/22 is written in over the white out marks. The agency acknowledges that this is not proper correction of any error that might have occurred.

Upon client record review, 2 of 15 (Patient #13, 14) did not have evidence that the discharge summary includes all required information. Patient#13, 14: Discharge summaries lack clinical summary of patients' stay.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Upon observation and interview with staff, there is no evidence that the agency provided a copy of policies/procedures on management and disposal of controlled drugs. The information was added to admission packets prior to end of survey.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Upon observation, there was no documented evidence that the agency provided education regarding disposal of controlled drugs.

Upon client record review, 10 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.