Every finding on record at Bespoke Hospice Care LLC

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Actual or potential drug interactions Patient #8: The medication profile listed Eucerin cream was applied topically but, there was no evidence of where (route) the cream was to be applied. Additionally, MiraLAX 17gm was listed on the medication profile, but there were no instructions for a diluent.

Upon patient record review, 1 of 14 (Patient #3) 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: The RN assessment dated 01/23/24 and MSW assessment dated 01/24/24 documented the bereavement assessment was, "completed by chaplain" however, there was no evidence the chaplain completed the bereavement assessment.

Upon patient record review, 2 of 14 (Patient #9,#13) 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 #9: The patient's initial and all following care plans listed interventions and goals for COPD, but there was no evidence that COPD was documented as a primary or comorbid diagnosis nor was COPD corroborated by the MD CTI or the initial RN assessment. Additionally, the patient's hospice diagnosis was Heart Failure, but there was no evidence of a cardiac care plan. Patient #13: The MD CTI and the patient's diagnosis list indicated the patient's hospice diagnosis was CVA with visual disturbances and extensive dysphagia, with comorbid diagnoses of idiopathic epilepsy with tonic-clonic seizures. However, there was no evidence that Neurological goals or interventions or seizure precautions were part of the patient's plan of care.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: The SCC visited the patient on 08/08/25 for a routine visit; 08/12/25 for a PRN visit; 08/15/25 routine visit, and 08/22/25 PRN visit. However, the plans of care for the same time periods indicated the frequency was 1 month 3 with 3 PRN visits. Additionally, the SCC documented at each visit, "the plan continues at 1 x month."

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6:The aide care plan dated 02/09/26 documented the tasks of 1) assist with transfers and 2) change patient linens were assigned "as needed."

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 Annual report for 2025 documented volunteers provide 4.16% of total patient care hours of all paid hospice employees.

Upon patient client record review, 1 of 14 (Patient #13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #13: The Election of Benefit signed 07/01/25 did not identify the attending physician as evidenced by the acceptance or declination of an attending physician was left blank.

Upon patient record review, 1 of 7 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Oxygen concentrator noted at the bedside during home visit. RN stated during home visit that he has it ordered PRN for shortness of breath. Did not have evidence of oxygen listed on the MAR. Corrected on-site.

Upon patient record review, 1 of 7 (Patient #1) 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 1: Oxygen concentrator noted at the bedside during home visit. RN stated during home visit that he has it ordered PRN for shortness of breath. Did not have evidence of oxygen ever being ordered. Corrected on-site.

Upon patient record review 2 of 7 (Patient # 2, 3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 2: Oxygen ordered at the time of admit. Did not have evidence of Oxygen being in the ALF at the time of survey. Corrected during survey. Patient 3: Oxygen ordered at the time of admit. Did not have evidence of Oxygen being in the home at the time of survey. Corrected during survey.