Every finding on record at Tlc Hospice of Austin, LLC

Upon patient record review, 5 of 11 records (Patients #2,#3,#4,#7,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patients 2,3,4,7,11: The medical records contained documentation identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profiles. Corrected on site for current patients.

Upon patient record review, 5 of 11 records (Patients #2,#3,#4,#7,#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. Patient 2,3,4,7,11: The medical records contained documentation identifying patient use of oxygen. There was no evidence of orders for oxygen in the medical records. Corrected on site for current patients.

Upon patient record review, 2 of 11 records (Patients #1,#6) 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. Patients 1 and 6: The medical records contained nursing documentation identifying patient use of walker. There was no evidence of the walker included as DME on the plans of care. Corrected on site.

Upon observation of the home visits, 1 of 3 applicable (Patient 2) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2: RN placed bag on chair without cleansing or use of barrier per agency policy. The RN also was witnessed placing dirty oximeter and blood pressure cuff in designated clean area of bag.

Upon patient record review, 2 of 4 applicable records (Patients #3,#4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 3: The medical record contained a CTI for 11/3/21 signed 10/26/21 prior to face to face completion 11/2/21 and a CTI for 7/1/22 signed 6/21/22 prior to face to face completion 6/23/22. There was no evidence that the narrative was composed with consideration of the findings during the face to face evaluations. Patient 4: The medical record contained a CTI for 6/5/22 signed 5/24/22 prior to face to face completion 5/26/22. There was no evidence that the narrative was composed with consideration of the findings during the face to face evaluation.

Upon patient client record review, 1 of 11 records (Patient #11) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient 11: The medical record contains a election of benefits form and consents showing receipt of patient rights with dates of 11/6/21 and 11/7/21 both typed on the forms for election/SOC date. It is unclear on the forms the elected date chosen by patient and family however forms signed by patient representative 11/7/21 and signed by hospice representative 11/6/21. SOC was 11/7/21.

Upon patient client record review, 3 of 11 records (Patients #3,#4,#10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures. Patient 3: CTI signed 3/1 states for BP 1/2-3/2. Addendum added for clarification that MD chose wrong BP date during documentation. Patient 4: F2F signed 5/26 states for BP 4/6-6/4 instead of BP starting 6/5. Addendum added for clarification that MD chose wrong BP date during documentation. Patient 10: CTI signed 3/1/22 states for BP 1/3/22-3/2/22. F2F signed 1/3/22 states for BP 3/4/22-5/2/22 instead of BP starting 1/3/22. F2F signed 3/1/22 states for BP 1/3/22-3/3/22 instead of BP starting 3/4/22. Corrected on site with addendum added for clarification that MD chose wrong BP dates during documentation.