Every finding on record at Aspire Hospice LLC

Upon patient record review, 2 of 14 (Patient #5,#9) 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 #5,#9: There was no evidence of a bereavement assessment completed within 5 days of admission.

Upon client record review, 4 of 14 (Patient #8,#10,#11,#12) 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 #8, #10, #11, #12: The comprehensive assessment update was completed on 11-26-24 and not again until 12-13-24 indicating greater than 15 days.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer hours are 3.8% and were reported to the board of directors who approved a PIP to increase the # of volunteers and the hours.

Upon client record review, 2 of 8 (Patient #1, 2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - POC dated 07/16/2021 SC frequency 1 time every 4 weeks. - No visit documented on week 12. MSW visit frequency 1 time every 4 weeks - no visit documented week 8. Patient #2 - POC dated 10/26/2021 SN visit frequency 1 x week - no visit week 1.

Upon review of policy and procedure, CNA Competencies did not define for hospice's that conduct an Aide Hospice competency evaluation program. The competency evaluation program includes, but is not limited to: CNA competency check off sheet did not contain the different types of shampoos to be completed: Shampoo, sink, tub, and bed

Upon patient record review 1 of 4 applicable patients (Patient #2) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2 - HHA visit schedule 3 x week effective 10/26/2021 but only 2 visit made week 1, 6 and 11.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards. Volunteer received general agency orientation. There was no a volunteer specific training program noted.

Upon SNF/NF contract review, 1 of 1 (WH) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.