Every finding on record at Yan Hospice Inc

Upon patient record review, 2 of 10 (Patient #8, 9) 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 418.7 • 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 #8 - Aide care plan contained task -shave every visit but did not state if safety razor or electric razor. Patient is on Plavix. Patient #9 - Patient has a foley catheter but the aide plan of care does not contain task -catheter care, empty drainage bag or s/s of infection.

Upon patient record review, 1 of 10 (Patient #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 #9 - SN visit note 04/03/25 and 04/05/25 contained "cleaned area around nephrostomy tube and new dressing applied", this is not specific for wound care. Also on 04/05/25 SN documented "Foley catheter changed" but did not document catheter size or output.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient records not available at survey prior to 9/1/2024.

Upon observation there was not evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. Agency uses Hospice MD software and has documentation of visit note but unable to provide DNR, copy of signed consents for care or a copy of the certification of terminal illness