Every finding on record at Believe Hospice, Inc.

Upon patient record review, 4 of 14 (Patient #1, 2, 5, 11) 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. Patient 1: The plan of care effective 05/19/25 records, "CHHA twice a week and daily as needed if change in condition x 60 days." Also, "RN once a week and daily as needed if change in condition x 60 days." The MSW and Spiritual Care frequencies reflect, "upon admission, recert, and as needed upon patient/pcg/family request." No evidence was found of a detailed scope and frequency of these disciplines to meet the individual patient and family needs. Patient 2: The plan of care effective 06/19/25 records, "RN once a week and daily prn for changes in status within 60 period of time," the MSW and Spiritual Care frequencies reflect, "upon admission, recert, and as needed upon patient/pcg/family request." No evidence was found of a detailed scope and frequency of these disciplines to meet the individual patient and family needs. Patient 5: The plan of care effective 05/19/25 records, "CHHA twice a week and daily as needed" Further records, "SN once a week and daily PRN for change in status within 60 days." The MSW and Spiritual Care frequencies reflect, "upon admission, recert, and as needed upon patient/pcg/family request." No evidence was found of a detailed scope and frequency of these disciplines to meet the individual patient and family needs. Patient 11: The plan of care effective 01/23/25 records, "RN once a week and daily pas needed if changes in condition x 90 days," the MSW and Spiritual Care frequencies reflect, "upon admission, recert, and as needed upon patient/pcg/family request." No evidence was found of a detailed scope and frequency of these disciplines to meet the individual patient and family needs.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There was no documented evidence of skilled nursing visits completed from 06/27/25 through the current date of 07/09/25. The plan of care indicates SN visit frequency is once weekly.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: Aide initial visit 06/12/25. No RN supervisory visit conducted until 06/27/25 which is day 15.