Every finding on record at Blue Ribbon Hospice Inc

Upon patient record review 2 of 7 (Patient #2,6) 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 2: No evidence that a full psychosocial assessment was completed. RN admission assessment states that the MSW was refused. Stated that she discussed code status and reviewed POLST form. No other evidence that the nurse completed a full assessment. No evidence that a full spiritual assessment was completed. RN admission assessment states that the Chaplain was refused. No evidence that any part of a spiritual assessment was completed. Patient 6: No evidence that a full psychosocial assessment was completed. RN admission assessment states that the MSW was refused. Psychosocial assessment stated that "the patient resides in an independent living home, she has family support, no mortuary plans in place." No evidence that a full spiritual assessment was completed. RN admission assessment states that the Chaplain was refused. No evidence that any part of a spiritual assessment was completed.

Upon patient record review, 4 of 7 (Patient #1,3,5,7) 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. Patients 1,3,5,7: SW and SC only have PRN orders on POC. No evidence of routine visits on calendar.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. No evidence that DME provider has CMS approved accreditation. No copy of the certificate or letter proving accreditation noted with DME contract.