Every finding on record at Southland Hospice Inc

Upon patient record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 4 of 14 (Patient #1,4,7,8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 4 of 14 (Patient #1,3,7,8) do not have evidence of the appropriate documentation for release of confidential information. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon patient record review, 11 of 14 (Patient #2,3,4,5,6,7,8,9,10,11,14) 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 #2,3,4,5,6,7,8,9,10,11,14: bereavement assessment only had first name of caregiver documented. No bereavement assessment was completed.

Upon patient record review, 12 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) 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: RN assessment 6/28/23, 9/24/23. Supervisory visits only on 10/4/23, 9/20/23, 9/6/23, 8/23/23, 8/9/23. Patient #2: RN assessment 8/3/23. Supervisory visits only on 8/17/23, 8/31/23, 9/14/23, 9/28/23. Patient #3: RN assessment 5/4/23, 8/2/23. Supervisory visit only on 10/5/23, 9/21/23, 9/7/23, 8/24/23, 8/10/23. Patient #4: RN assessment 6/24/23, 9/22/23. Supervisory visit only on 9/30/23, 9/16/23, 9/2/23. Patient #5: RN assessment 1/2/23, 4/2/23, 7/1/23, 8/30/23. Supervisory visit only on 10/9/23, 9/25/23, 9/11/23, 8/28/23. Patient #6: RN assessment 7/23/23. Supervisory visit only on 10/1/23, 9/17/23, 9/3/23, 8/20/23. Patient #7: RN assessment 4/17/23, 7/16/23, 9/12/23. Supervisory visit only on 10/2/23, 9/18/23, 9/4/23, 8/21/23, 8/7/23. Patient #8: RN assessment 4/4/23, 7/3/23, 10/1/23. Supervisory visit only on 10/3/23, 9/19/23, 9/5/23, 8/22/23, 8/8/23. Patient #9: RN assessment 3/30/23, 6/28/23, 9/26/23. Supervisory visit only on 9/28/23, 9/14/23, 8/31/23, 8/17/23. Patient #10: RN assessment 1/5/23, 4/5/23, 7/4/23, 9/2/23. Supervisory visit only on 9/28/23, 9/14/23, 8/31/23, 8/17/23. Patient #11: RN assessment 6/25/23. Supervisory visit only on 7/21/23, 7/7/23. Patient #12: RN assessment 4/1/23. Supervisory visit only on 4/29/23, 4/15/23.

Upon client record review, 2 of 14 (Patient #3, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: MSW frequency stated, eval may send 1 extra visit per benefit period per pt/family request. Patient seen for routine visits 5/5/23 and 7/26/23 for recert. SC frequency stated, eval may send 1 extra visit per benefit period per pt/family request. Patient seen for routine visits 5/6/23, 6/4/23, 7/2/23, 8/1/23, 9/20/23. Patient #4: LVN frequency 2x/week, seen only 1 time week of 7/10/23.

Upon patient record review1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #2: RN assessment documented on 8/3/23, patient requested hospice to contact local clergy. No documentation this was completed by SC.

Upon patient record review, 2 of 14 (Patient #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13: No 3 month bereavement letter was sent to family. Agency bereavement print out states due 8/19/23. Patient #14: No 6 month bereavement letter sent to family. Agency bereavement print out states due 9/30/23.

Upon patient record review 6 of 14 (Patient #1, #5, #6, #7, #8, #9) 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: HHA frequency 2x/week, seen only once first week, 6/29/23. Patient #5: Aide Care Plan did not have brush patient's teeth, Aide documented teeth were brushed on 4/10/23 and 2/23/23. Patient #6: HHA frequency 2x/week, seen only once first week, 8/17/23. Aide Care Plan states to change linen, not completed by HHA on 9/28/23. Diet was not assigned to complete on Aide Care Plan, HHA documented on 8/10/23 and 8/28/23. Patient #7: No frequency order for HHA until 7/18/23 for 2x/week. HHA visits completed by LVN on 5/2/23, 5/9/23, 5/23/23, 5/31/23, 6/5/23, 6/12/23, 6/19/23, 6/28/23. Aide Care Plan has bedbound, adult diapers, incontinence both bowel and bladder, gown, diet as tol, aspiration precaution, nails, deodorant, peri care, skin care. LVN did not complete tasks on 6/28/23. Patient #8: Aide Care Plan has bedbound, HHA did not document as completed on 7/18/23. Patient #9: Record of bowel movement was not on Aide Care Plan. HHA documented bowel movement on 8/3/23 and 9/28/23.

Upon patient client record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's. Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.

Upon client record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1: Patient signed own consents. RN documented on initial assessment patient is confused and disoriented. MSW documented on initial assessment, patient is confused and disoriented. Patient #3: Patient signed own consents. RN, MSW and SC all documented patient was alert and oriented x1. Patient #7: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Alzheimer's Patient #8: Patient consents signed by Admin of group home without proper authorization. Patient diagnosis is Cerebral Infarct.