Every finding on record at Beginning Life Hospice Inc

Upon patient record review, 4 of 5 (Patient 1-4) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1-4: No evidence in record that the comprehensive assessment took into consideration the imminence of death. Section left blank in each patient's comprehensive assessment.

Upon patient record review, 1 of 5 (Patient 5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 5: RN comprehensive assessment on 10/12/23 and subsequent RN visit note on 10/13/23 identified the presence of a "pigtail drain: on left chest wall of patient. No evidence in record that patient and family received education and training related to the safe and effective management of this.

Upon patient record review, 1 of 5 (Patient 5) 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: RN comprehensive assessment identified the presence of a "pigtail drain" in place to patient's left chest on 10/12/23. Plan of care did not address this problem with specific MD orders for care, verification of caregiver ability and frequency of draining schedule.

Upon patient record review, 1 of 5 (Patient #5) 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 medications and treatments. Patient 5: RN comprehensive assessment identified the presence of a "pigtail drain" in place to patient's left chest on 10/12/23. Plan of care did not address this problem with specific MD orders for care, verification of caregiver ability and frequency of draining schedule.

Upon patient record review, 5 of 5 (Patient 1-5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1-5: No evidence that imminence of death was assessed during the comprehensive assessment. Section on the form is left blank in the patient's record.

Upon patient record review, 1 of 5 (Patient 5) 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 5: No evidence of making bereavement services available to the family in the patient record. No evidence of a bereavement plan of care in medical record.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Agency has 2 patients that are invalid for this survey. Patients 4 and 5 were admitted prior to the licensure survey that was completed 11/16/21 and therefor are invalid patients for this survey.