Every finding on record at Silver Years Healthcare, Inc.

Upon patient record review 3 of 11 (Patient # 8, 9, 10) 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 #8, MSW declined 10/31/20. No evidence of a psychosocial assessment completed as part of the comprehensive assessment. Patient #9, MSW declined. No evidence of a psychosocial assessment completed as part of the comprehensive assessment. Patient #10, No assessment completed by SC and MSW. No evidence of a psychosocial or spiritual assessment completed as part of the comprehensive assessment.

Upon patient record review, 1 of 11 (Patient # 1) 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, O2 at 2lpm/nc, may increase to 3-5l/nc if O2 sat less than 88%. Order written on treatment plan and not Medication profile.

Upon client record review, 4 of 11 (Patient # 8, 9, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8, RN frequency order 1x/week. RN visits completed twice week of 11/2/20. Patient #9, RN frequency order 2x/month. RN Visits 9/30/20, 10/7/20, 10/17/20, 10/18,20,10/19/20. Patient #10, RN frequency order every 14 days and sup visit, no other SN frequency order. RN visits 9/3/20, 9/4/20, 9/9/20, 9/17/20. Patient #11, SN frequency 1x/week, visits 8/4/20, 8/6/20, 8/6/20, 8/11/20, 8/16/20, 8/19/20, 8/26/20, 8/28/20.

Upon patient record review 3 of 7 applicable (Patient #7, 8, 11) 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 #7, Aide ordered 2x/week on the initial plan of care. Week of 5/4/22, only one aide visit was made. No missed visit documentation. Patient #8, Aide order 2x/week, only one Aide visit the first week of 9/30/20. Patient #11, Aide order 2x/week on 8/4/20, HHA visits started on 8/18/20, no HHA visits first 2 week nor missed visits documented.

Upon patient client record review, 4 of 11 (Patient # 8, 9, 10, 11) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Patient #8, No signature on SC 11/2/20 assessment, no signature on MSW assessment on 11/2/20 Patient #9, No Signature on IDG notes from MD, SC on 10/2/20, 10/16/20, 10/30/20. Patient #10, No signature on IDG notes for SC on 9/3/20, MD, RN, SC on 9/4/20 and 9/18/20 Patient #11, No signature on IDG notes for RN on 8/4/20, MD, RN, SC on 8/21/20.

Upon patient client record review, 1 of 11 (Patient # 7) 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 #7, Emergency Preparedness plan completed at start of care listed O2 prn 2-4L via NC. This was listed in error. Patient was not ordered oxygen.

Upon client record review, 1 of 4 applicable (Patient # 10) did not have evidence that the discharge summary includes all required information. It did not include a summary of the patient's stay.