Every finding on record at Bright Star Hospice Care Inc

Upon patient record review 1 of 5 (Patient #2) 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 - SOC 5/30/25, documented patient declines social worker and no evidence of an order however, the chart showed evidence of a routine MSW visit completed on 6/19/25. There was no evidence that a psychosocial assessment was completed on this patient by a MSW.

Upon patient record review, 1 of 5 (Patient #1) 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 - The patient had Lantus sub-q and Janumet orally both ordered to be given daily. The medical record showed no evidence of problems, goals or interventions related to the endocrine system in the plan of care.

Upon patient record review, 1 of 5 (Patient #2) 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 equipment and supply needs. Patient #2 - The initial nursing comprehensive showed documented evidence that the patient was incontinent of bowel and bladder. There was no evidence that those incontinent supplies were listed on the patients plan of care. This was corrected onsite

Upon client record review, 2 of 5 (Patient #2,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 - Upon admission, patient declined MSW visits. The admission IDG on 05/30/25 also documents patient declined these visits. On 06/19/25, the MSW completed a routine visit with no order. This was corrected onsite and an order was obtained. Patient #5 - Upon admission, patient declined MSW visits. The IDG update dated 06/02/25 had documentation present which also stated patient had declined MSW visits. The record showed evidence that a MSW visit was completed on 06/18/25 with no order. This was corrected onsite and an order was obtained.