Every finding on record at Triage Hospice LLC

Upon patient record review 2 of 6 (Patient #4, #6) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4,6: According to the comprehensive assessment dated 06-20-23, the patient declined a visit by the MSW. However, there was no evidence the psychosocial assessment was completed within 5 days by any member of the IDG.

Upon patient record review, 1 of 6 (Patient #5) 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 therapy currently associated with laboratory monitoring Patient #5: A medication order for O2 2L NC was entered on the Plan of Care and CTI dated 04-22-24, however, Oxygen was not listed on the medication profile.

Upon patient record review, 1 of 6 (Patient #5) 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 #5: The patient's hospice diagnosis was Heart Failure and there was no evidence of a care plan for cardiac concerns.

Upon patient record review, 1 of 6 (Patient #5) 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 #5: The comprehensive assessment and medication profile dated 04-22-25 indicated the patient was using Tylenol with codeine PRN and Colace. However, the HIS measure N0510 for PRN opioid was marked "No" and HIS measure N0520 for bowel regimen was marked "No".

Upon observation there was not evidence the agency was in compliance with maintaining patient records. The agency indicated they did not retain access to medical records of patients who were admitted or discharged prior to 06-20-23.

Upon patient record review, 2 of 6 (Patient #3,#5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. Patient #3, #5: The was no evidence in the patient record that the IDG determined the patient or family's ability to safely administer medications.