Every finding on record at Agape Group Inc

Upon observation and home visits, 1 of 3 (Patient #1)there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #1 was admitted to service. He and his wife, who is his caregiver are Spanish speaking. They do not speak English. There was no evidence of a written notice of patient's Rights and Responsibilities being provided to the patient/caregiver in a language that the patient/caregiver understands.

Upon patient record review, 2 of 14 (Patient #5, 8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect 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 #5: This patient is a full code and there is no evidence of interventions or goals for advanced care planning or code status. Patient #8: This patient is a full code and there is no evidence of interventions or goals for advanced care planning or code status.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #1-10: The RN completed the initial spiritual care assessment per requirements on all patients. However, the IDG has ordered spiritual care for initial visit and PRN. PRN visits may not be ordered to stand alone or without a reason for the PRN.

Upon client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients #1-10: The IDG ordered spiritual care for initial visit and prn. There is no evidence of a spiritual care visit being completed by the spiritual care provider.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13: There was evidence of a phone call attempt made one time on this caregiver. There is no evidence of a bereavement plan of care. Patient #14: There was documentation of one call made to caregiver and message left, no further follow up. There is no evidence of a bereavement plan of care.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance During the survey it was noted that several care plans for one patient were written/entered into the record by the LVN and is not within the LVN acceptable standards of practice.

Upon patient record review, 4 of 11 (Patients #1, #4, #5 and #7) 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. Patients #1, #4, #5 and #7 had orders for nebulizer treatments, the DME nebulizer machine was not included on POC. Corrected on site.

Upon patient record review 2 of 11 (Patient #2 and #9) 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 #2: The POC listed Aide visit frequency of 2 X's per week. For the 1st Benefit Week there was only one visit on 12/27/22. Patient #9: The POC listed Aide visit frequency of 2 X's per week. For the 1st Benefit Week there was only one visit on 12/7/22.