Every finding on record at 1 Heart Hospice and Palliative Care, Inc

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #5: The SC discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature or no related notation to validate participation in 3/25/25 IDG meeting/review.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: Patient admitted with brain mass and history of seizure/epilepsy. There is no reference to seizure precautions in Hospice Aide assignment sheet. The option to check is left blank.

Upon patient client record review, 1 of 14 (Patient #5) 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: Page 3 of consent form does not include details of POA filed in EMR. Space to identify POA is blank.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #8: The Plan of Care does not specify which provider is accountable for SNF resident's catheter changes, wound care and GT site care/maintenance, feedings.

Upon patient record review, 1 of 11 records (Patient #5) 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. Patient #5: There was not evidence of a bereavement assessment.

Upon patient record review, 2 of 11 records (Patient #1 and 8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The record indicated on the social work documentation that the daughter was in denial regarding the patient's rapid decline in condition. There was not end of life arrangements, the bereavement assessment had documented anticipatory grief, and the POLST indicated that the patient/representative still wanted some heroic measures. There was not evidence of care plan problems with goals and interventions related to the psychosocial well-being of the patient and representative, or end of life planning. Patient #8: The record indicated that the patient was incontinent of bowel and bladder. Also, the patient developed a skin tear on her chest, dated 4/7/22 which required treatment. Her skin was fragile and easily bruised. There was not evidence of goals and interventions related to skin issues.

Upon client record review, 3 of 10 applicable records (Patient #3,#4,#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: The social work visit frequency was 1x/month. The record indicated only 2 visits by the social worker since admission (11/5/21 and 5/2/22). Patient #4: The spiritual care visit frequency was to do an evaluation then 1 visit every certification period. The record indicated 2 scheduled visits in March (3/11/22 and 3/25/22). The certification period was 3/1/22-5/29/22. Patient #11: The social worker visit frequency was an evaluation then every certification. The first certification period was 8/17/21-11/14/21. The record indicated that the social worker conducted an evaluation upon admission and a visit on 10/25/21.

Upon patient record review 1 of 11 records (Patient #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3: Documentation in a communication note by the social worker dated 1/26/22 indicated that the social worker spoke with the patient's family regarding the patient's medical condition and possible transfer to a SNF. There was not evidence of follow up.

Upon patient record review, 1 of 5 applicable records (Patient #3) did not have evidence that before the recertification period for each patient, the medical director or physician designee reviewed the patient's clinical information and provided written documentation that it is anticipated that the patient's life expectancy is 6 months or less. There was not evidence that the physician provided a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #3: There was not evidence of a narrative statement.

Upon patient client record review, 1 of 11 records (Patient #11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #11: The record indicated that the patient/representative wished to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The date of request was 8/17/21 (admission). The document was prepared and signed by the agency on 8/18/21. The patient/representative signed and dated the document on 9/2/22.

Upon patient client record review, 1 of 11 records (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. Patient #10: The nurse note dated 12/11/22 (death) indicated that controlled medication counted and endorsed to facility staff... All other documentation in the record indicated that the patient was in her own residence, not a facility.

Upon client record review, 1 of 1 applicable records (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The visit frequency for the SN was 2x/week. There was not evidence of a visit for the week of 5/1/22-5/7/22.