Every finding on record at Prestige Hospice Inc

Upon patient record review, 3 of 14 (Patient #1,2,3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2,3, Initial psychosocial assessment did not identify funeral home. No evidence of funeral home planning documented on plan of care.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4, No evidence of clinical information documented in narrative by the Medical Director.

Upon patient record review, 5 of 5 records (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 5 (Patient #2, #3) 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 2: The comprehensive assessment shows evidence of patient having back pain with ambulation and movement and that pain is relieved by medication. There is no evidence of pain medication on the medication profile. The medication profile contains triamcinolone acetonide 0.1%, apply to affected area daily. There is no evidence of a location to apply. Corrected on site. Patient 3: The comprehensive assessment shows evidence of patient having intermittent back pain with ambulation and movement. The RN documented breakthrough medication being used less than daily and medication is what makes the pain better. There is no evidence of pain medication on medication profile.

Upon patient record review, 2 of 5 (Patient #2, #3) 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 2: The comprehensive assessment shows evidence of patient having back pain with ambulation and movement and that pain is relieved by medication. There is no evidence of an order for pain medication. The plan of care contains an order for triamcinolone acetonide 0.1%, apply to affected area daily. There is no evidence of quantification. Corrected on site. Patient 3: The comprehensive assessment shows evidence of patient having intermittent back pain with ambulation and movement. The RN documented breakthrough medication being used less than daily and medication is what makes the pain better. There is no evidence of an order for pain medication.

Upon client record review, 1 of 5 (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: The plan of care contains an order for SN visits 1 time per week. There is evidence of 2 SN visits being performed the week of 2-6-22--2-12-22 there is no evidence of either visit being PRN.

Upon patient record review 1 of 1 applicable records (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 4: The clinical record shows evidence of the aide completing visits to patient on 1-24-22, 1-27-22, 1-31-22, 2-3-22. There is no evidence of an order for aides on the plan of care.

Upon patient client record review, 1 of 5 records (Patient #1) did not have evidence that each patient record contains: Patient 1: The medical record contains a notification of hospice non-covered items, services, and drugs with no evidence of signature by patient.

Upon patient client record review, 1 of 5 records (Patient #4) 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 4: The clinical record contains narrative documentation by the RN 2-12-22, the pt was discharged and the discharge summary was sent to MD. There is evidence that the patient was not discharged until 2-15-22 when pt revoked hospice.