Artemis Hospice and Palliative Care

“Upon patient record review, 4 of 14 (Patients #1,2,4,6) 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: This patient had a fall pad. This was not included on the Plan of Care. Corrected on site. Patient #2: This patient had a walker and wheel chair. These were not included on the Plan of Care. Corrected on site. Patient #4: The record reflected that this patient had a wheel chair. This was not included on the Plan of Care. Corrected on site. Patient #6: The record reflected that this patient had a hospital bed, suction machine, O2 concentrator and a wheel chair. These were not included on the Plan of Care. Corrected on site.”

“Upon patient record review, 7 of 14 (Patients #1,2,3,4,6,7,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The POC listed LVN visit frequency of, 2 X’s per week (9/6/24). There were no visits made by LVN for first or second Benefit Weeks. Patient #2: The POC listed LVN Visits 2X’s per week (10/11/24). During 1st Benefit week there were no visits made by the LVN. Patient #3: The POC listed LVN visit frequency of, 2 X’s per week (8/2/24). During 1st Benefit week there were no visits made by the LVN. Patients #4: The POC listed LVN Visits 2X’s per week (11/1/24). During 1st Benefit week there were no visits made by the LVN. For second Benefit week there was one visit only on 11/6/24. Patient #6: The POC listed LVN Visits 2X’s per week (9/20/24). During 1st Benefit week there were no visits made by the LVN. Patient #7: The POC listed LVN visit frequency of, 2 X’s per week (10/10/24). For first Benefit Week there was only one visit on 10/11/24. Patient #12: The POC listed LVN Visits 1X’s per week (6/22/24). During 1st Benefit week there were no visits made by the LVN.”

“Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personal #9: These following competencies from 42 CFR 418.76(3)(b) were not evaluated as direct observation while the aide is performing the tasks with a patient or pseudo-patient. They were only validated by verbal competency. ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient.”

“Upon patient record review 8 of 14 (Patients #1,2,3,4,5,6,7,12) 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 Patient #1: The POC listed Aide visit frequency of, 2 X’s per week (9/6/24). For first Benefit Week there was only one visit on 9/7/24. Patient #2: The POC listed Aide Visits 2X’s per week (10/11/24). During 1st Benefit week there were no visits made by the Aide. Patient #3: The POC listed Aide visit frequency of, 2 X’s per week (8/2/24). For first Benefit Week there was only one visit on 8/2/24. Patients #4 and #5: The POC listed Aide Visits 2X’s per week (11/1/24). During 1st Benefit week there were no visits made by the Aide. Patient #6: The POC listed Aide Visits 2X’s per week (9/20/24). During 1st Benefit week there were no visits made by the Aide. Patient #7: The POC listed Aide visit frequency of, 2 X’s per week (10/10/24). For first Benefit Week there was only one visit on 10/11/24. Patient #12: The POC listed Aide Visits 2X’s per week (6/22/24). During 1st Benefit week there were no visits made by the Aide.”

“Upon patient record review, 1 of 14 (Patient #10) 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 #10: This patent discharged from hospice services on 9/6/24. In discharge narrative there was a conflicting date in body of note that indicated DC date 9/1/24 (not 9/6/24). This date did not match other discharge indicators in heading of form (9/6/24).”