Every finding on record at United Hospice Services, Inc.

Upon patient record review, 2 of 14 (Patient #5, #7) 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. . Patient #5-On 06/05/23 the nurse documents the patient has Robitussin for cough. Robitussin is not included in the medication profile. Patient #7-The medication profile includes Prometh Plain 6.25mg/5ml syrup dosage 1 syrup (dosage unclear) every 6 hours prn cough/phlegm.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a complete 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 #4-The bereavement risk assessment on record dated 09/16/22 does not include the name and relationship of the individual being assessed.

Upon patient record review, 7 of 14 (Patient #1, #2, #4, #5, #6, #7, #8 ) did not have evidence in the patient record that the comprehensive assessment is updated including and by: the hospice interdisciplinary group no less frequently than every 15 days. Patient #1, #2, #4, #5, #6, #7, #8-Each of the records did not evidence the RN visited no less frequently than every 15 days to perform a comprehensive assessment and reassess the patients response to care. Nursing was ordered to visit weekly on each of the records. The RN visited monthly and at recertification. All other visits were performed by the LVN.

Upon patient record review, 2 of 14 (Patient #5, #7) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including all medications. Patient #5-On 06/05/23 the nurse documents the patient has Robitussin for cough. Robitussin is not included in the plan of care. Patient #7-The plan of care includes Prometh Plain 6.25mg/5ml syrup dosage 1 syrup (dosage unclear) every 6 hours prn cough/phlegm.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence in the Aide personnel file that the following competency assessment was performed by the aide with a patient: Shampoo, sink, tub, and bed. Personnel #6-The Aide competency on record only documents the aide was observed providing a shampoo. The documentation does not specify the Aide was observed performing a shampoo in the sink, tub, and bed.

Upon patient record review, 14 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) did not evidence a complete election statement. Each of the records do not clearly identify the effective date of the election. The effective date of election may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive. The election statements do not include identification of the attending physician. The individual or representative must acknowledge the identified attending physician was his or her choice. The right to request Patient Notification of Hospice non covered items, services and drugs was not included in the election statement. The Beneficiary and Family Centered Care Quality organization name and phone number is not included in the election statements.

Upon patient record review, 4 of 14 (Patient #2, #5, #7, #11) did not have evidence that all entries are appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2- The 05/06/22 comprehensive assessment is not electronically signed by the RN. The 06/08/23 and 07/06/23 chaplain visits do not contain a signature. Patient #5-The 08/19/22 spiritual assessment does not contain an electronic signature. Patient #7-The 10/22/22 chaplain visit note does not contain an electronic signature. Patient #11-The 08/27/22 nursing assessment note does not contain an electronic signature.