Every finding on record at Vms Palliative Hospice Care, LLC

Upon patient record review, 3 of 13 records (Patient #2, #6, #11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 2, 6, and 11: There was no evidence of the patient choosing a health care provider/attending physician.

Upon patient record review 13 of 13 records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13: Pt declined SC. There was no evidence of a spiritual assessment.

Upon patient record review, 4 of 13 records (Patient #2, #8, #9, #10) 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 2: Order dated 2/23/2022 included O2LPM via n/c prn SOB. There was no evidence of the O2 on the medication profile. Order Corrected on site. Patient 8: In nurses documentation for 4/6/2022 continuous oxygen 5L via n/c. Dated 4/20/2022 continuous O2 4/ via n/c. Dated 5/18/2022 continuous O2 3L per n/c. There was no evidence of O2 on the medication profile. Order corrected on site. Patient 9: Order dated 2/22/2022 O2 concentrator. On SOC HIS questions dated 2/22/2022 oxygen prn as ordered. Pt SOB at rest, dim lung sounds, wheezing. There was no evidence O2 on the medication profile. Corrected on site. Patient 10: In IDG notes dated 3/23/2022, 4/6/2022, 4/20/2022 nurse narrative includes on continuous O2. There is a Dr. order dated 3/22/2022 O2 concentrator. There was no evidence of O2 on the medication profile. Corrected on site.

Upon patient record review, 1 of 13 records (Patient #8) 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 8: In nurses documentation for 4/6/2022 continuous oxygen 5L via n/c. Dated 4/20/2022 continuous O2 4/ via n/c. Dated 5/18/2022 continuous O2 3L per n/c. There was no evidence of an order for O2. Corrected on site.

Upon client record review, 3 of 13 records (Patient #3, #7, #10) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 3, 7, 10: There was no evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Updated plan of care. Corrected on site.

Upon client record review, 2 of 13 records (Patient #1,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Order dated 4/6/2022 SW 1 x month. There was no evidence of a SW visit or missed visit for April. Patient 6: Order dated 4/6/2022 for MSW 1x week, there was no evidence of MSW visits made after 4/6/2022. Order dated 4/6/2022 for SC 1x week, there was no evidence of SC visits made after 4/6/2022. Corrected on site.

Upon observation, 2 of 3 applicable (Patients 2 and 3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2: SN opened clean bag with stethoscope, measuring tape, penlight, got in and out of clean bag without cleansing hands during pt care. Patient 3: SN opened clean bag with stethoscope, measuring tape, penlight, got in and out of clean bag without cleansing hands during pt care.

Upon patient record review 1 of 6 applicable records (Patient #2) 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 2: HHA visits on SOC order includes 2x week start 2/24/2022. Plan of care in IDG ordered at 2x week dated 3/23/2022, 4/6/2022, 4/20/2022, 5/4/2022. There was no evidence of any HHA visits since start of care.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon client record review, 2 of 2 applicable records (Patient #11, #12) did not have evidence that the discharge summary includes all required information. Patient 11: Revoked care, to obtain further care in hospital, was imminently dying there was no evidence of a discharge summary. Did not have evidence of notification to client/family or attending of pts discharge for no longer terminally ill. Patient 12: Discharged due to no longer terminally ill, there was no evidence of a discharge summary.