Every finding on record at Prime Palliative Care Inc

Upon patient record review 4 of 14 (Patient #2,3,6,8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2,3 SC declined, no spiritual assessment on initial RN assessment, comments state PCG and family member state patient does not practice specific Religion. Patient #6, 8 SC declined, no spiritual assessment on initial RN assessment.

Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SN frequency 1x/week, visits made 3/6/23, 3/8/23, 3/15/23, 3/20/23, 3/22/23, 3/29/23, 4/3/23, 4/6/23. Patient #2, SN frequency 1x/week, visits made 3/13/23, 3/15/23, 3/20/23, 3/27/23, 3/29/23, 4/5/23, 4/10/23, 4/12/23. Patient #3, SN frequency 1x/week, visits made 1/18/23, 1/19/23, 1/23/23, 1/25/23, 2/1/23, 2/6/23, 2/8/23, 2/15/23, 2/20/23, 2/22/22. Patient #4, SN frequency 1x/week, visits made 4/5/23, 4/6/23, 4/13/23, 4/19/23, 4/27/23. Patient #5, SN frequency 1x/week, visits made 5/1/23, 5/2/23, 5/9/23, 5/15/23. Patient #6, SN frequency 1x/week, visits made 2/1/23, 2/6/23, 2/13/23, 2/15/23, 2/20/23, 2/27/23, 3/1/23, 3/6/23, 3/13/23, 3/15/23. Patient #7, SN frequency 1x/week, visits made 2/17/23, 2/20/23, 2/27/23, 3/3/23, 3/6/23, 3/13/23, 3/17/23, 3/20/23. Patient #8, SN frequency 1x/week, visits made 1/13/23, 1/14/23, 1/21/23, 1/27/23, 1/28/23, Patient #9, SN frequency 1x/week, visits made 2/1/23, 2/3/23, 2/8/23, 2/15/23LVN, 2/15/23 RN, 2/22/23, 2/27/23, 3/1/23, 3/8/23. Patient #10, SN frequency 1x/week, visits made 2/1/23, 2/3/23, 2/8/23, 2/14/23, 2/16/23. Patient #11, SN frequency 1x/week, visits made 7/22/22, 7/23/22, 7/31/22. Patient #12, SN frequency 1x/week, visits made 2/3/23, 2/4/23, 2/8/23, 2/15/23, 2/17/23, 2/22/23 Patient #13, SN frequency 1x/week, visits made 2/5/22, 2/8/22, 2/18/22, 2/19/22, 2/23/22, 3/4/22, 3/5/22.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,2, RN went in and out of her nursing bag without sanitizing her hands. Patient #3, LPN went in and out of her nursing bag without sanitizing her hands.

Upon patient record review 4 of 14 (Patient #2,6,9,10) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2, Aide plan of care instructs nail care every visit, not completed on 3/16/23, 3/23/23, 3/27/23. Patient #6, Aide plan of care instructs to ambulate with walker, not documented on 2/1/23, 5/3/23, 5/8/23, 5/10/23, 5/12/23. Patient #9, Aide plan of care instructs to ambulate with wheelchair, not documented on 2/9/23, 2/16/23, 2/22/23. Patient #10, Aide plan of care instructs to ambulate with wheelchair, not documented on 2/9/23.

Upon patient client record review, 5 of 14 (Patient #2,3,6,8,10) 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 #2, IDG note on 3/13/23 missing SC signature. Patient #3, IDG note on 1/19/23 missing SC signature. IDG note on 5/15/23 no RN signature. Patient #6, IDG note on 2/1/23 missing MD signature. Patient #8, IDG note on 1/13/23 missing SC signature. Patient #10, IDG note on 2/1/23 missing SC signature.