Every finding on record at Aurora Hospice Care, Inc.

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #1, 2, 3, LVN did not have name badge on her person to identify herself to the patients.

Upon patient record review 8 of 14 (Patient #5,6,7,8,12,13,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5,6,7,8,12,13,14, No spiritual assessment evaluation by the SC and RN assessment was not completed for spiritual assessment.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14, Missing consideration of imminence of death upon comprehensive assessment.

Upon patient record review, 3 of 14 (Patient #3, 4, 6) 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 #3, BR assessment had no name of family/caregiver for follow up after death. Patient #4, BR assessment had last name of patient's name for first name of the bereaved, assessment incomplete. Patient #6, BR assessment had letter J for bereaved name, assessment incomplete.

Upon patient record review, 11 of 14 (Patient #1,2,3,4,5,7,10,11,12,13,14) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patients #1,2,3,4,5,7,10,11,12,13,14 RN completed supervisory visits however only completed one assessment of the patient at initial admission and then at the recertification.

Upon patient record review, 12 of 14 (Patient #3,4,5,6,7,8,9,10,11,12,13,14) 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 #3,4,5,6,7,8,9,10,11,12,13,14, Missing care plan for psych-social.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, 2, 3, LVN went in and out of her bag without hand sanitizing her hands.

Upon patient record review, 1 of 14 (Patient #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 #14, No documentation of letters sent to patient family after death from 1 month through to the 13 month letters.