Every finding on record at Benevolence Hospice

Upon observation, there was not evidence of the Hospice having any written contracts/agreements with other Facilities/Agencies/Hospices to receive Benevolence's patients in the event that Benevolence cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 11 (Patient #10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. A verbal order was obtained 12/30/21 for, "Colostomy care daily and as needed." This is not a complete order, as it does not delineate 'who' is responsible for this daily intervention, nor an indication for such 'as needed' colostomy care. The POC dated 12/30/21 included, "Patient has a Foley Catheter." This is not a complete order, as it does not delineate the details of such medical supply, to include but not limited to: Catheter size, saline balloon size, the frequency of when it is to be changed and by whom, and the daily maintenance of this supply. This patient lived in an ALF.

Upon patient record review, 2 of 11 (Patients #2 and 8) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions; specifically all Equipment and Supply needs: Patient #2: During Surveyor-attended home visit on 04/26/22, the patient was sitting in her wheel chair. This DME was not included on her POC. Patient #8: The record reflected that this patient had a DME of walker. The walker was not included on the POC.

Upon patient record review, 1 of 11 (Patient #6) did not contain evidence that a revised Plan of Care included the information gathered from the patient's updated comprehensive assessment(s). An RN documented on the 03/29/22 visit note that, "the caregiver reported that the patient had experienced an episode of depression and sadness, and cries nonstop." This patient status information, and any indicated interventions/goals were not included within the next subsequent IDG Plan of Care, as a problem/area of concern.

Upon patient record review, 1 of 11 (Patient #4) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Plan of Care. The SOC Plan of Care dated 02/04/22 included, "PT Evaluation." The ongoing IDG POC dated 04/21/22 continued to include this intervention. There was no evidence in the clinical record of this order having been completed.

Upon patient record review, 2 of 7 applicable (Patients #3 and 10) did not contain evidence that the RN- prepared, Hospice Aide POC/assignment included the details of all assigned tasks, and all other pertinent patient information. Patients #3 and 10, the clinical record reflected that these patients had a Physician-ordered D.N.R. This pertinent information was not included on their Aide POC.

Upon patient record review, 1 of 11 (Patient #1) did not contain evidence that all entries were complete, and appropriately authenticated/dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Aide visits were ordered, and completed on a weekly frequency for this patient. However, the Aide visit notes for 03/22, 03/29, 04/05, 04/12, and 04/19/22 were not yet completed, signed/dated, and filed within the record. A supervising RN was able to confirm that these visits had been completed, the visit notes had been started but not completed, nor signed/dated as of 04/26/22. This was corrected on-site.

Upon patient record review, 1 of 1 applicable live discharge (Patient #9) did not contain evidence that the Discharge Summary included all CMS-required content, as follows: • The patient's current Plan of Care • The patient's latest Physician orders

Upon inpatient contract review, 1 of 1 applicable (Grand Valley Healthcare/GIP/RIP) did not contain a provision that: A copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from the in-patient Facility.