Every finding on record at Committed Hospice Care Inc

Upon patient record review, 1 of 15 (Patient #1) 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 #1: The Initial Bereavement Risk Assessment was not completed timely. Patient SOC 4/18/22, the BR Risk Assessment was completed on 5/10/23.

Upon patient record review, 11 of 15 (Patients #1,3,4,6,7,9,11,12,13,14,15) 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 Patient #1: MSW visit frequency (5/19/23) indicates per month as needed. This frequency did not include baseline visit frequency for MSW Patient #3: SC visit frequency (5/3/22) indicates PRN. MSW visit frequency (6/3/22) indicates as needed and recert. These frequencies did not include a baseline for SC or MSW. Patient #4: SC visit frequency (8/28/23) indicates 1x mo and as needed. MSW visit frequency (8/28/23) indicates as needed and recert. These frequencies did not include amount of PRN visits for SC/MSW. Patient #6: MSW visit frequency (9/21/23) indicates 1x per month as needed. This frequency did not include amount of PRN visits for the MSW. Patient #7: MSW visit frequency (6/22/22) indicates 1x per month as needed. This frequency did not include amount of PRN visits for the MSW. Patient #9:SC visit frequency (9/28/23) indicates per month as needed. MSW visit frequency (9/28/23) indicates per month as needed. These frequencies did not include baseline frequency or amount of PRN visits for SC/MSW. Patient #11: SC visit frequency (9/22/23) indicates of PRN as needed. This frequency did not include a baseline visit frequency for the SC. Patient #12: MSW visit frequency (3/9/23) indicates 1x per month as needed. This frequency did not include amount of PRN visits for the MSW. Patient #13: SC visit frequency (2/28/23) indicates as needed and recert. This visit frequency did not include amount of PRN visits for the SC. Patient #14: SC and MSW visit frequency (8/28/23) indicates 1x mo and as needed. These visit frequencies did not include amount of PRN visits for SC/MSW Patient #15: SC visit frequency (1/19/23) indicates 1x mo and as needed. MSW every recert and as needed. These visit frequencies did not include amount of PRN visits for SC/MSW.

Upon patient record review, 2 of 15 (Patient #2, 3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #2: The Aide had visit frequency of 2x week plus 1 PRN. The order did not indicate if patient was cognizant to make own decisions. Patient #3: The Aide visit frequency indicated 1 or 2 as needed. This frequency did not include a baseline for Aide.

Upon patient record review 5 of 15 (Patient #1,5,7,9,14) 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 #1: The Aide Visit Frequency ordered (1/17/24) was 2 x week plus 1 PRN. The 1st Benefit Week the aide visited on 1/19/24 only. Patient #5: The Aide Visit Frequency ordered (10/28/23) was 2 x week. The 1st Benefit Week the aide visited on 10/31/23 only. Patient #7: The Aide Visit Frequency ordered (6/30.22) was 2 x week. The 1st Benefit Week there were no visits by the Aide. Patient #9: The Aide Visit Frequency ordered (9/28/23) was 2 x week. The 1st Benefit Week the aide visited on 9/28/23 only. Patient #14: The Aide Visit Frequency ordered (12/1/22) was 2 x week. The 1st Benefit Week the aide visited on 12/3/22 only.