Every finding on record at Bniv Care Inc.

Upon patient record review, 4 of 5 (Patient #1-4) 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. Patients #1-4 Visit frequencies for the spiritual care and SW are indicated for 1x month, there is no evidence of spiritual and psychosocial problem statements with goals, interventions and progress toward outcomes for any of the patients. The goals for the nursing problems are not measurable or quantitative and are without a target date for goal outcomes. There is no problem statement referring to ADL's or assistance for the hospice aide services, although the aide is assigned and providing care to each patient.

Upon patient record review, 1 of 5 (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 The patient has a medication order for Miralax that does not include the frequency of use.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) 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 #1, 2, 3, 4, 5, 6, 7, 9, 10, 11 had SW and SC services provided and there was not evidence of specific problems, goals, and interventions for spiritual and psychosocial problems identified. Patient #5 comprehensive assessment identified that patient had aspiration precautions and constipation which were not addressed in the plans, goals and interventions in the plan of care. Patient #6 comprehensive assessment identified that patient had history and risks of aspiration and constipation which were not addressed in the plans, goals and interventions in the plan of care. Patient #7 comprehensive assessment identified that patient had diarrhea, shortness of breath and is on Oxygen which were not addressed in the plans, goals and interventions in the plan of care. Patient #8 SW services provided as as identified in the patient medical record and there was not evidence of specific problems, goals, and interventions for psychosocial problems identified.

Upon patient record review, 11 of 11 (Patient ##1, 2, 3, 4, 5, 6, 7, 8, 9, 10, & 11) 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. All of the patients had a medication profile and there was no evidence of orders for any of the medications on the medication profile.

Upon patient record review, 10 of 11 (Patient #1,2,3,4,5,6,7,8,9 & 11) the plan of care did not include the equipment's of the patient's which are necessary for the palliation and management of the terminal illness and related conditions, which was also stated in the agency policy #L on Plan of Care that DME and medical supplies are to be included in the Plan of Care. Patient #1 had a cane and Oxygen as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #2 had a walker as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #3 had a walker as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #4 had an air mattress, hospital bed, Oxygen machine as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #5 had a walker and Oxygen machine as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #6 had a suction machine, Oxygen machine, hospital bed, wheelchair as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #7 had a walker and Oxygen machine as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #8 had a need for an air mattress, overbed table, wheelchair, shower chair, etank as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #9 had a walker, air mattress, hospital bed, overbed table, wheelchair,, as identified and included in the comprehensive nursing assessment. No evidence of an order for DME. Patient #11 had a hospital bed, air mattress, overbed table, wheelchair, Hoyer lift, nebulizer, and a suction machine as identified and included in the comprehensive nursing assessment. No evidence of an order for DME.

Upon patient record review 1 of 11 (Patient #8) 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 #8 the patient was not provided with the air mattress, overbed table, wheelchair, shower chair, e-tank which were identified as needed by the patient in the comprehensive assessment dated 9-03-2021 and are related to end of life care needs, palliation and management of the terminal illness and related conditions.

Upon client record review, 1 of 1 applicable (Patient #8) the discharge summary was not sent to the physician upon discharge. the patient chose revocation of election for hospice benefits.

Upon observation, there was no evidence of a current CLIA certificate, the CLIA certificate expired on 12-04-2020.