Every finding on record at Affinity Hospice Care Inc

Upon patient record review, 2 of 6 (Patient # 1 and 2) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: The comprehensive assessment at SOC on 09/01/25 does not show evidence of assessment of imminence of death. Patient 2: The comprehensive assessment at SOC on 09/01/25 does not show evidence of assessment of imminence of death.

Upon patient client record review, 1 of 6 (Patient # 2) 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 2: Revocation note on 11/08/25 indicates patient desire to seek treatment at hospital and patient is forfeiting remainder of benefit period 2 however, patient records indicate he is discharging while in certification period 1.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Agency was not able to provide all medical records at the agency on Day 1 of survey. Agency had to obtain medical records from the previous owner for survey record review.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Agency was not able to provide all medical records on Day 1 of survey. Agency was able to obtain 3 past medical records from previous owner for survey record review on Day 3.