Every finding on record at S&G Hospice Inc

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #13: Section on consent forms for "Right to Chose an attending physician" were left blank. It is unclear if they did or didn't want to choose an attending physician.

Upon patient record review, 2 of 14 (Patient #3, 5) 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 #3: Patient medication profile and POC contains order for diclofenac 1% topical gel to affected areas and an order for neosporin topical to cellulitis. Site not specified. Patient #5: Patient medication profile and POC contains order for diclofenac 1% topical gel to affected areas. Site not specified.

Upon patient client record review, 1 of 14 (Patient #13) did not have evidence that each patient record contains Advance Directives. Patient #13:Physician Orders for Life-Sustaining Treatment (POLST) form was signed by the legal representative but not by the physician.

Upon patient client record review, 6 of 14 (Patient #2, 4, 5, 7, 11, 12) 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: Initial Bereavement Assessment not signed by clinician Patient #4: MSW visit on 6/10 not signed by clinician. Initial Bereavement Assessment not signed by clinician. Aide visits on 6/5 and 6/17 not signed by aide. Patient #5: MSW visit on 6/8 not signed by clinician. Patient #7: Page 1 of 2 of Election of Hospice Medicare Benefit, Right to Request Patient Notification of Hospice Non-Covered items: Both boxes "I elect" and "I decline" to receive were check marked. It is unclear which one was the correct response. Patient #11: Page 2 of 2 of Election of Hospice Medicare Benefit signed by patients daughter. Reason patient is unable to sign box left blank. Patient #12: Initial Bereavement Assessment not signed by clinician.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #9: No evidence that the discharge summary was sent to the attending MD.