Every finding on record at St. Alex Hospice Care Inc.

Upon patient record review, 1 of 6 (Patient #4) 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 #4 Oxygen is listed on the medication profile but there is no evidence of respiratory problems, goals and interventions on the plan of care.

Upon patient record review, 2 of 6 (Patient #2 & #4) 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 equipment and supply needs. Patient #2 RN initial assessment dated 7/27/23 identified need for walker, cane and incontinent supplies but these are not included in the plan of care. Corrected on site by receiving clarification orders from a physician. Patient #4 Medication profile indicates the use of oxygen but oxygen equipment is not listed under DME in the plan of care.

Upon patient record review, 1 of 6 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4 Aide Care plan duties assigned by RN on 10/12/22 included tub/shower for bathing and WC/Walker/Cane for ambulation.

Upon patient record review 1 of 6 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Permitted to be performed under state law by such hospice aide Patient #4 Completed Aide visit note of 10/17/22 included done next to tub/shower and WC/Walker/Cane without specification of which items were completed.