Every finding on record at West Coast Palliative Care Inc

Upon client record review, 6 of 11 (Patient #3,4,6,7,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3, MSW frequency 1x/month, visit completed on 11/3/22 and tele visit completed 11/28/22 completed. Patient #4, SN frequency 1x/week, SN visits on 11/15/22 and 11/16/22. Patient #6, SN frequency 1x/week, SN visits on 8/1/22 and 8/2/22. Patient #7, SN frequency 1x/week, SN visits on 11/8/22 and 11/9/22. Patient #10, SN frequency 2x/month, SN visits made 1/4/22, 1/7/22, 1/11/22, 1/14/22, 1/21/22, 11/25/22, 1/28/22. Patient #11, SN frequency 1x/week, SN visits on 2/10/22 and 2/11/22.

Upon patient record review, 3 of 11 (Patient #1,8,10) 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 #1, Aide plan of care had both shower and bed bath without directions when to provide which bath. Patient #8, Aide plan of care documents nail care weekly without directions on which day to complete. HHA frequency 2x/week. Patient #10, Aide plan of care states nail care weekly without directions of which day. Aide frequency 2x/week.

Upon patient record review 3 of 11 (Patient #1,6,10) 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, Nail care ordered on plan of care to be completed weekly, completed 2x/week. Change clothes and dress ordered on care plan every visit, no documentation of task being completed. Patient #6, Bed bath, shampoo, comb hair, oral hygiene, skin care, peri care, nail care completed every visit 2x/week when aide care plan states 1x/week. Patient #10, Care plan states to complete nail care, no documentation of nail care completed.

Upon patient client record review, 11 of 11 (Patient #1,2,3,4,5,6,7,8,9,10,11) 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 #1,2,3,4,5,6,7,8,9,10,11 No credentials documented with all signatures on IDG notes.