Every finding on record at Right Choice Hospice & Palliative Care Inc

Upon patient record review 1 of 14 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient#2: There is no evidence of an comprehensive spiritual assessment being completed within 5 days. No spiritual visit made until 1/9/25, patient admitted 8/14/24.

Upon patient record review 3 of 14 (Patient #5,#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#5: There is no evidence of a comprehensive spiritual assessment being completed within 5 days. On 9/19/24 visit was assigned to spiritual coordinator who documents that services were declined. No assessment noted. Patient#6: There is no evidence of a comprehensive spiritual assessment being completed within 5 days. It was noted on a 9/24/24 visit assigned to spiritual that services were declined. Patient#8: There is no evidence of an comprehensive psychosocial assessment being completed within 5 days. RN documented on initial visit that MSW services were declined.

Upon patient record review, 3 of 14 (Patient #1,#5,#8) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The record indicates patient was ordered oxygen to use in home PRN on admit. There is no evidence of oxygen listed on medication profile. Corrected on site. Patient#5: The record indicates patient was ordered Capsiderm topical patch on admit. There is no evidence of specific instructions for application on medication profile. Corrected on site. Patient#8: The record indicates Diclofenac Sodium 1% Topical Gel was ordered on 8/14/24. There is no evidence of specified area of application on medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#1: The record indicates RN was assigned visits on 9/21/24, 10/5, 10/19, 11/16, 11/30, and 12/14. There is no evidence of of vital signs, assessment, narrative, or RN signature for these visits therefore no evidence of comprehensive assessment at lease every 15 days.

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient#1: There are no notes from any discipline on IDG's for 11/11/24, 11/25, 12/9, 12/23, 1/6/25, and 1/20/25. Only the MSW signed the IDG notes for 11/11/24, 11/25, 12/9, 12/23, 1/6/25, and 1/20/25. IDG's for 10/28/24 and 10/14 only had notes from RN and didn't have any signatures from IDG team. Patient#2: IDG's on 12/23/24, 1/6/25, 1/20, and 2/3 had no evidence of signatures from any discipline. . Patient#3: IDG's for 1/20/25 and 2/3/25 had no evidence of any signatures from any discipline. IDG's for 11/25/24, 12/9, 12/23, 1/6/25 had no evidence of notes or signatures from any discipline. Patient#4: There is no evidence of any notes or signatures from any discipline on 1/20/25. Patient#5: The record indicates for IDG on 2/3/25 that only the RN and MSW signed. For IDG on 12/23/24, 1/6/25, and 1/20/25 there is only evidence that the MSW signed.

Upon patient record review, 1 of 14 (Patient #6) 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. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#6: The record indicates patient was admitted with terminal diagnosis of hypertensive heart disease without heart failure. There is no evidence of problems goals or interventions related to this diagnosis. Corrected on site.

Upon patient record review, 2 of 14 (Patient #5,#8) 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#5: The record indicates patient was ordered Capsiderm topical patch on admit. There is no evidence of specific instructions for application on the order. Corrected on site. Patient#8: The record indicates Diclofenac Sodium 1% Topical Gel was ordered on 8/14/24. There is no evidence of specified area of application on the order. Corrected on site.

Upon client record review, 2 of 14 (Patient #1,#4) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient#1: There is no evidence of an IDG being completed for this patient on 2/3/25 or on 2/17/25. Patient#4: There is no evidence of IDG being completed for this patient on 2/3/25 or 2/27/25.

Upon client record review, 9 of 14 (Patient#1,#2,#4,#5,#6,#7,#8,#9,#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: The record indicates LVN was assigned visits on 11/28/24, 12/5, 12/12, 12/19, and 12/26. There is no evidence of of vital signs, assessment, narrative, or LVN signature for these visits. The record indicates RN was assigned visits on 9/21/24, 10/5, 10/19, 11/16, 11/30, and 12/14. There is no evidence of of vital signs, assessment, narrative, or RN signature for these visits. Patient#2: The record indicates spiritual services were declined per order on 8/14/24. Spiritual visits were made on 1/9/25 and 2/11/25. There is no evidence of a frequency order for these visits. Patient#4: The record indicates spiritual services declined per order on 8/12/24. There is evidence of spiritual visits made on 1/30/25 and 2/11/25. There is no evidence of a new order for spiritual visits. Patient#5: The record indicates there is an order for spiritual visits one time per month. There is no evidence of spiritual visits made for October, November, or December. Patient#6: The record indicates on 9/24/24 that spiritual services were declined. The record also indicates a spiritual visit was made on 1/21/25. There is no evidence of an order for this visit. There is an order on 9/21/24 for MSW to make an initial visit and one visit for each recertification. These visits were completed. The record indicates MSW also made visits on 10/20/24, 11/19/24, and 1/18/24. There is no evidence of an order for these visits. Patient#7: The record indicates spiritual made visits on 1/21/25 and 2/12/25. There is no evidence of an order for these visits. The record also indicates MSW made visits on 11/23/24, 12/22, and 1/21/25. There is no evidence of an order for these visits. The only order in chart was at admit for visits to be made for initial assessment with in 5 days. Patient#8: The record indicates an order on 11/2/24 states spiritual services were declined. There is evidence spiritual visits were made on 1/21/25 and 2/12/25. There is no order for these visits. The record indicates an order on 11/4/24 states MSW services were declined. There is documentation the MSW made visit on 1/28/25. There is no evidence of an order for this visit. Patient#9: The record indicates spiritual visit made on 1/9/25 and 2/13/25. MSW made visits on 12/3/24 and 1/28/25. There is no evidence of an order for these visits. The only order in chart only states for each discipline to make a visit for initial assessment within 5 days. Patient#10: The record indicates spiritual visit made on 1/27/25. MSW made a visit on 1/7/25. There is no evidence of an order for these visits.

Upon patient record review, 1 of 14 (Patient #2) 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#2: There is no evidence of a physician narrative or signature on initial CTI. Corrected on site.

Upon patient record review, 3 of 14 (Patient #1,#2,#4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient#1: There is no evidence of a physician signature or date for CTI's for the second, third, fourth, and fifth benefit periods. Corrected on site. Patient#2: There is no evidence of a physician narrative or signature on the CTI for second and third benefit periods. Corrected on site. Patient#4: There is no evidence of a physician narrative or signature on CTI for second benefit period. There is no evidence of a physician signature on CTI for third benefit period. Corrected on site.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: During home visit, MSW stated that she had made home visit to patient in February 2022 There was no order and no visit note in medical record. There was documentation that the patient refused social work services.

Upon personnel record review, 1 of 1 applicable records (Personnel #4 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·(C) Shampoo, sink, tub, and bed Patient Record #4: The HA competency checklist does not differentiate competency for various shampoo types (sink, bub, bath), therefore, unable to validate demonstrated competence in these tasks. Discussed/education staff.

Upon patient client record review, 1 of 5 (Patient #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. Patient Record #5: SN Visit Note 1/24/22 identifies level of care as continuous. Other documentation and interview with leadership confirms patient is serviced at routine level of care.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. All active patient records are kept in a secure location. Patient record information is safeguarded against loss or unauthorized use. On day 1 of survey, the agency indicated that there were 5 unduplicated admission. Agency was only able to provide 2/5 patient records. When agency was asked for the 3 records, was told that the RN had the records and would be bringing them in. 1 was received later in the day. the other 2 were available at the start of day 2. There was no evidence the agency protected PHI by securing all patient records on the agency premises.