Every finding on record at Reality Care Hospice, Inc.

Upon client record review, 2 of 14 (Patient #1,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: POC dated 01/14/2025 has an order for the SC to completed an eval for the episode that started 01/14/2025. The initial Chaplain documentation stated that the patient requested monthly visits. Documentation from the patient's initial IDG indicated that the patient requested monthly visits. No evidence that an order was received for the visit during the month of February. Patient 10: POC dated 11/20/2024 has no order for Volunteer to eval. The volunteer visited the patient monthly from January - February. No evidence of an order for these visits.

Upon personnel record review, 1 of 11 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel 2: No evidence of a signed job description for the role of alternate administrator. Corrected on site.

Upon patient client record review, 3 of 14 (Patient #1,2,5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1: Page #1 of 2 of the Election of Medicare Hospice Benefit has spouses name written in the patient name spot instead of the patient name being written in. Patient 2: Page #1 of 2 of the Election of Medicare Hospice Benefit has patient's daughter name written in the patient name spot instead of the patient name being written in. Patient 5: Page #1 of 2 of the Election of Medicare Hospice Benefit has patient's daughter name written in the patient name spot instead of the patient name being written in.

Upon patient client record review, 3 of 14 (Patient #1,2,5) 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. unauthorized access to the patient records. Patient 1:Informed Consent form page 1 has spouses name written in the patient name spot. Patient was unable to sign consents themselves and spouse signed all forms. Patient 2:Informed Consent form page 1 has daughter's name written in the patient name spot. Patient was unable to sign consents themselves and daughter signed all forms. Patient 5: Informed Consent form page 1 has daughter's name written in the patient name spot. Patient was unable to sign consents themselves and daughter signed all forms.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient 11: No evidence that the discharge summary included a summary of the patient's stay. No evidence that it included treatments, symptoms, pain management, current plan of care, or the patient's latest physician orders. Patient 12: No evidence that the discharge summary included a summary of the patient's stay. No evidence that it included treatments, symptoms, pain management, current plan of care, or the patient's latest physician orders.

Observed in Record Review. In 5 of 5 patient records reviewed, The HCO did not ensure patient care plan goals were individualized, measurable, and include appropriate time frames. Examples include the following: “will have reduced stress levels...CG will demonstrate ability to cope w/pt's altered mental status w/in 2 wks period of time. Pt will receive prescribed medications at correct times. Pt/CG will receive optimal teaching and support at cardiac and pulmonary functions change during care. Pt/cg will achieve optimal grief reaction prior to pt's death. CG will demonstrate ability to cope with pt's AMS w/in 2 wk period of time. Pt's pain will remain at comfortable level during care w/in 2 wks period of time. Skin integrity will be maintained during care w/in 2wks period of time.Pt/Caregiver will receive optimal teaching and support as cardiac and pulmonary functions change during care. Terminal Care/Impending Death care plan on admission. These goals do not contain specific information, including time frames and diagnosis specificity that can be accurately measured, to assist staff in determining whether the patient is progressing towards goal achievement. These findings were reviewed, discussed, and validated with the organization’s Assistant DPCS/Assistant Administrator.