Every finding on record at Red Oak Hospice LLC

Upon patient record review, 1 of 19 (Patient #7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #7: Initial and continued IDG POC SN frequency is 1wk13 and 10 PRN. The PRN number of visits is broad, and if needed would indicate visit frequency adjustment.

Upon patient record review, 1 of 19 (Patient #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 #3: 8/30/23 Physician order for wound care to gluteal wound is not specific to left, right or bilaterally- regarding wound location.

Upon client record review, 2 of 19 (Patient #2,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: SN Visit note dated 10/17/23 includes "Wound care dressing change per protocol". 10/24/23 note includes "Wound care/dressing change per care plan." Notes are not specifics to care actually provided. Patient #6: 11/01/23 SN note regarding wound care to gluteus, is not specific in that it notes "Wound cleansing/dressing change per care plan".

Upon patient record review 2 of 19 (Patient #2, 3) 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: Missed HA visits r/t staff absence HA Sept. 28, 29 and Oct 2, 2023. There is note that patient and MD aware. There is no note related to possible replacement offered for staffing the visit. It is noted no staffing needed by facility. Patient #3: Missed HA visits r/t staff absence Oct. 6 and 19, 2023. There is notation that patient and MD aware. There is no note related to possible replacement offered for staffing the visit. It is noted no staffing needed by facility.

Upon patient client record review, 1 of 19 (Patient #1) 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: CTI inadvertently refers to patient as 23 year old instead of 93 year old.