Every finding on record at V & G Hospice Inc

Upon patient record review, 5 of 14 (Patient #1,5,6,8,9) 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 1: The current plan of care has the SW frequency set as one monthly in person visit to start in January 2025. The medical record indicated that the SW completed all scheduled monthly visits via telephone. No evidence that an order was received by the physician to change the type of visits or that this was done at the request of the patient/caregiver. Patient 5: The current plan of care has the SW frequency set as one monthly in person visit. Starting in October 2024, the medical record indicated that the SW completed all scheduled monthly visits via telephone. No evidence that an order was received by the physician to change the type of visits or that this was done at the request of the patient/caregiver. Patient 6: The current plan of care has the SW frequency set as one monthly in person visit. Starting March 2025, the medical record indicated that the SW completed all scheduled monthly visits via telephone. No evidence that an order was received by the physician to change the type of visits or that this was done at the request of the patient/caregiver. Patient 8: The current plan of care has the SW frequency set as one monthly in person visit. The medical record indicated that the SW completed the visits for the months of October 2024, November 2024, January 2025, and March 2025 were completed via telephone. No evidence that an order was received by the physician to change the type of visits or that this was done at the request of the patient/caregiver. Patient 9: The current plan of caredhas the SW frequency set as one monthly in person visit. The medical record indicated that the SW completed the visits for the months of October 2024, December 2024, and February 2025 were completed via telephone. No evidence that an order was received by the physician to change the type of visits or that this was done at the request of the patient/caregiver.

Upon patient client record review, 3 of 14 (Patient #7,8,10) 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 7: No evidence that the effective date of election was added to the election statement. Patient 8: No evidence that the effective date of election was added to the election statement. Patient 10: No evidence that the patient identified an attending physician at the time of election.

Upon patient record review, 2 of 5 records (Patient #1,#3) 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 1: The nursing care plan contains altered metabolism related to insulin and an intervention to assess blood glucose. The plan of care does not contain an order to assess blood glucose. Corrected on site. Patient 3: The plan of care contains an order "May change-insert 14fr foley catheter and provide catheter care every 3-4 for as needed." There is no evidence of frequency. Family member reports to SN that the SN does not need to irrigate the foley today as she already had. There is no evidence of an order to flush the foley catheter in the plan of care. Corrected on site.

Upon patient record review, 2 of 5 records (Patient #1,#3) 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 plan of care indicates patient had diabetes and blood sugars are to be monitored. There is no evidence of a glucometer, lancets, or alcohol wipes listed as DME. Patient 3: Upon home visit patient had a trapeze on their bed. There is not evidence of a trapeze listed in the plan of care. Corrected on site.

Upon patient client record review, 1 of 5 (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. Patient 5: The medical record contains a revocation form dated 2-16-22. The patient signed and dated the form 2-3-22 (date of admission). The medical record contains and IDG dated 2-18-22 with a narrative note documenting "patient revoked today 2-16-22".

Upon observation, there was missing evidence the organization follows their policies and procedures to maintain the the patient's clinical record/information in confidential manner. During home visit of patient #3, the LVN in conversation with surveyor, voiced the last name of patient #1 in front of patient and family.