Brytelyte Homecare LLC

“Upon patient record review 8 of 16 (Patient #1, #2, #3,#4,#6, #10, #11, #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1, #3, #4, #6, #10: There was no evidence of a psychosocial assessment completed within 5 days of the admission. Patient #2, #12: There was no evidence of a psychosocial assessment or spiritual assessment completed within 5 days of the admission. Patient #11: There was no evidence of a spiritual assessment completed within 5 days of the admission.”

“Upon patient record review, 4 of 16 (Patient #2,#4,#5, #9) 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: The MD recertification narrative indicated the patient was using oxygen at 2L per NC. However, there was no evidence of O2 2L per NC on the medication profile. Patient #4: The written Cert by the MD indicated the patient was on O2 2L NC. There was no evidence of O2 on the medication profile. Patient #5: Per the MD Cert and the admission assessment both dated 4-7-23, the patient was using O2 up to 3L per NC. There was no evidence of O2 on the medication profile. Patient #9: Per the MD Cert on 05-07-24 the patient was using O2 at 2L NC. There was no evidence that O2 was on the medication profile.”

“Upon patient record review, 5 of 16 (Patient #2, #3, #4, #6, #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2, #3, #4, #6, #12: There was no evidence of a bereavement assessment completed within 5 days.”

“Upon patient record review 1 of 16 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #2:There was no evidence of an aide supervisory visit by the RN after 06/04/24 until 08/05/24 while the aide continued to visit the patient 2 x per week.”

“Upon patient record review, 1 of 16 (Patient #8) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #8: There was no evidence of a narrative which included subjective and objective clinical findings, current medication and treatment orders, or medical management of the patient’s condition on the written certification for BP 02-14-22 - 05-14-22.”

“Upon patient record review, 2 of 16 (Patient #5,#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 #5: There was no evidence of a date for the MSW signature on the MSW assessment of 4-10-23. Patient #11: There was no evidence of a date after the signature of the MSW for assessment of 01-17-23.”