Every finding on record at Clear Path Healthcare Services Inc.

Upon patient record review, 2 of 5 (Patients #1,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1,4: The medical records contained orders for oxygen. There was no evidence of the oxygen included on the medication profiles.

Upon patient record review, 1 of 5 (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 medical record contained an initial bereavement assessment dated 4/1/23. Patient did not admit until 9/20/23.

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

Upon patient record review, 1 of 5 (Patient #3) 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 3: The medical record contains nursing documentation upon admission identifying patient is an aspiration risk. There was no evidence of problems, goals, and interventions related to aspiration.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The medical record contained nursing documentation upon admission and throughout care identifying wound care including application of medihoney and wound dressings. There was no evidence of an order for wound care.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, wheelchair, and walker. There was no evidence of the bed, wheelchair, and walker included as DME in the plan of care.

Upon personnel record review, 1 of 11 (Personnel #7) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel 7: There was no evidence the bereavement coordinator was qualified in accordance with professional standards. The agency did not have evidence of educational background.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 5 of 5 (Patients #1,#2,#3,#4,#5) did not have evidence in the patient record that hospice aide assignments and duties were legible and clear. Patients 1,2,3,4,5: The aide care plans contained task to report diastolic blood pressures >90->60. Patients 1,2,3 corrected on site.

Upon patient record review 1 of 5 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 4: The aide care plan contained an ordered task for ROM to be completed with the patient every visit. There was no evidence of the aide completing the task at any visit scheduled three times weekly while on service.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.