Every finding on record at USA Hospice, Inc.

Upon patient record review, 2 of 14 (Patient #1,7) 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. 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 Patient #1, 7, order for oxygen 2-5lpm via nasal cannula as needed for shortness of breath. Oxygen was listed on treatment sheet and was not documented on medication profile.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14-There was no evidence the plan of care reflects the patient/family goals and interventions for care being provided by social worker and spiritual care.

Upon patient record review, 1 of 14 (Patient #1) 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 #1, The oxygen and wheelchair were not listed on the plan of care.

Upon patient record review, 3 of 14 (Patient #1, #2, #11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1, Patient care plan was not updated with wound care orders. No updated care plan for foley cath, Foley cath removed on 5/30/23. Patient #2, Patient care plan was not updated with wound care orders. Patient #11, Patient care plan was not updated with wound care orders.

Upon client record review, 10 of 14 (Patient #2,3,5,6,7,8,9,10,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2,5,6,7,8,9,12,13, No order for MSW phone assessment. Patient #3, LVN frequency 1x/week, first LVN visit 8/22/23. Missed first week. Patient #10, No order for MSW and SC phone assessment. LVN frequency 1x/week, First LVN visit 4/30/23, missed first week.

Upon patient record review, 2 of 14 (Patient #4,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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, No vital sign parameters on aide care plan. Patient #14, No vital sign parameters on aide care plan.

Upon patient record review 6 of 14 (Patient #1, #3, #10 #12, #13, #14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, HHA frequency 2x/week, seen only 1x the first week. Patient seen twice on 7/2/23 by 2 different aides. Patient #3, HHA frequency ordered 1x/week, no visits made, no order to d/c HHA. Patient #10, HHA frequency ordered 2x/week, no visits made the first week. First HHA visit 5/1/23, 5/5/23, 5/8/23, 5/12/23. Patient #11, HHA frequency ordered 2x/week, no visits made the first week. First HHA visit 3/14/23, 3/17/23, 3/21/23, 3/28/23. Patient #12, HHA frequency ordered 2x/week, no visit made until 2/14/23. Visits 2/14/23, 2/21/23, 2/28/23, 3/3/23. In addition, Aide visit 3/10/23 fall risk was instructed to complete on plan of care and was not documented as completed. Patient #13, HHA frequency ordered 2x/week, visits made 3/11/23, 3/14/23, 3/17/23, 3/20/23. Patient #14, HHA frequency ordered 2x/week, 5/13/23, 5/16/23, 5/19/23, 5/23/23, 5/26/23, 5/30/23, 6/3/23.

Upon patient record review, 2 of 14 (Patient #2,13) 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 #2, CTI was not signed from 7/12/23. Patient #13, CTI was not signed from 4/7/23.

Upon patient client record review, 1 of 14 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5, The effective date was not documented on election of hospice benefit consent form.

Upon patient client record review, 2 of 14 (Patient #5, #10) did not have evidence that each patient record contains Advance Directives. Patient #5, Consent does not address if patient has or does not have an Advance Directive. Boxes to verify if patients had or did not have was left empty. Patient #10, Consent does not address if patient has or does not have an Advance Directive. Boxes to verify if patients had or did not have was left empty.

Upon patient client record review, 2 of 14 (Patient #8, #9) 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 #8, missing MD signature on IDG document on 5/26/23, 8/4/23, 8/18/23, 9/1/23. Patient #9, missing MSW signature on IDG document on 11/1/22, 11/11/22.