Every finding on record at Throne Hospice, Inc

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #8: The Election of Benefit form to choose an attending physician was not filled in as follows: "I do not wish to choose attending physician" or "I acknowledge that my choice for an attending physician" neither of these boxes were checked on form or the physician name handwritten in space provided on the form.

Upon patient record review, 2 of 14 (Patients #6,11) 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 Patients #6,11: The initial POC indicated oxygen for DME Supplies. There was no evidence of oxygen included on the medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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 #1: This patient has an order for oxygen 2-5 L/min for PRN (9/9/23). The plan of care does not include respiratory measures/goals.

Upon patient record review, 6 of 14 (Patients #1,2,4,5,8.9) 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 #1: The MSW and SC indicated "as needed" for visit frequency (9/9/23). This frequency did not include a baseline visit frequency for the MSW/SC. Patient #2: The MSW "as needed" for visit frequency (10/5/23). This frequency did not include a baseline visit frequency for the MSW. Patient #4: The MSW "as needed" for visit frequency (8/2/23). This frequency did not include a baseline visit frequency for the MSW. Patient #5: The MSW and SC indicated "as needed" for visit frequency (9/15/23). This frequency did not include a baseline visit frequency for the MSW/SC. Patient #8: The SC indicated "as needed" for visit frequency (2/6/23). This frequency did not include a baseline visit frequency for the SC. Patient #9: The MSW "as needed" for visit frequency (5/31.23/23). This frequency did not include a baseline visit frequency for the MSW.

Upon patient record review, 2 of 14 (Patients #6,11) 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. Patients #6,11: The POC indicated oxygen for DME Supplies. There was not a medication order for O2 on POC.

Upon personnel record review, 1 of 11 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient or pseudo-patient: Personnel #8: The CHHA Initial Competency had verbal verification for digital thermometers, urinal and ROM. These skills were not observed/demonstrated as required.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #8: The Election of Benefit form choice of attending physician was not filled in as follows: "I do not wish to choose attending physician" or "I acknowledge that my choice for an attending physician" neither of these boxes were checked on form or physician name added in space provided. Also, the choice to receive notification of non-covered items was checked as decline, however there was no date beside initial.

Upon patient client record review, 1 of 14 (Patient #1) 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 1: The initial nursing note indicated patient is on 2-3L/min oxygen PRN (9/9/23). The medication list indicated oxygen 2-5 L/min PRN (9/9/23). The initial POC indicated the oxygen 2L/min (9/9/23). These directions for oxygen use do not match, the nursing note, med list and/or POC all have different liters per minute listed.

Upon SNF/NF contract review, 1 of 4 (the Chandler Convalescent Hospital contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.