Every finding on record at Rsag Hospice, Inc.

Upon patient record review, 1 of 10 (Patient #7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #7 - Consent was blank regarding the patients choice of a health care provider, including an attending physician.

Upon patient record review, 2 of 10 (Patient #5, 10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5 - MSW documented completion of bereavement assessment on 05/04/24 but no evidence assessment was completed; no patient visit/phone call was made since admission. Patient #10 - MSW documented completion of bereavement assessment on 04/02/24 but no evidence assessment was completed; no patient visit/phone call was made since admission.

Upon patient record review, 1 of 10 (Patient #4) 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 #4-No patient visits were made to patient after initial assessment and PRN visit frequency not documented. MSW frequency was written as PRN.

Upon patient record review, 1 of 10 (Patient #1) 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 #1 - Wound care being provided by outside agency but orders for the wound care to the R lower extremity and lateral foot not on POC dated 03/28/24.

Upon patient record review, 3 of 10 (Patient #2, 4, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 - POC dated 03/08/24 SN visit frequency 2 x week only 1 visit made week 1. Patient #4 - MSW visit frequency order at recertification and PRN; Patient admitted 1/31/24 and has not had visit since the initial. Patient #5 - POC dated 04/30/24 SN visit frequency 1 x wk and 3 PRN - PRN visit made 05/01, 05/02, 05/09, 05/10 and 05/17/24 - no additional PRN visit ordered for additional 2 PRN visits.

Upon patient record review 2 of 10 (Patient #1, 7) 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 #1 - Aide care plan contained peri care every visit but aide did not provide 04/12/24 or 05/15/24. Aide assisted with feeding patient on 05/15/24 but care plan does not contain "assist with feeding". Patient #7 - Aide care plan contained shower every visit but aide provided bed bath on 05/07/24 and 05/16/24. Aide fed patient breakfast on 04/09/24 but care plan does not contain "assist with feeding". Visit frequency 2x week but only 1 visit documented week 9.

Upon patient record review, 2 of 10 (Patient #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 Patient #2 - Home health aide visit note on 04/17/24 aide dated signed on 04/16/24 and visit note on 05/01/24 aide dated signed by HHA on 04/30/24. SN documented "provided wound care"on visit note 05/06/24, 05/09/24 and 05/20/24 - did not document specific wound care provided. Patient #5 - SN visit note on 05/07/24, 05/14/24 and 05/21/24 did not document amount or description of drainage from biliary drainage tube.

Upon observation there was not evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time from the acquired agency. Agency was acquired in 2023 - Prior to acquiring all patients were discharged and records do not exist for these patients. This agency's first patient was admitted 01/31/2024.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12 - Agency unable to obtain documentation of licensed contract personnel from agency they have contract with, due to not providing SLP since they started admitting patients.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #11- Agency unable to obtain documentation of licensed contract personnel from agency they have contract with, due to not providing OT since they started admitting patients.

Upon personnel record review, 1 of 12 (Personnel #10) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #10-Agency unable to obtain documentation of licensed contract personnel from agency they have contract with, due to not providing PT since they started admitting patients.

Upon personnel record review, 3 of 12 (Personnel #10, 11,12 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #10, 11, 12 - Agency unable to obtain documentation of background check on contract personnel from agency they have contract with, due to not providing PT, OT or SLP since they started admitting patients.