Every finding on record at Commonwealth Hospice

Upon patient record review, 3 of 3 (Patient #1,#2,#3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law.

Upon patient record review, 1 of 3 (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 was admitted 2/16/22. The Bereavement Assessment was dated 5/23/22.

Upon patient record review, 1 of 3 (Patient #2) 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. Patient #2 Recert POC dated 5/19/22 Ordered Spiritual Care frequency at 3 PRN.

Upon patient record review, 2 of 2 applicable (Patient #1,#2) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient Patient #1,#2 Upon SNF clinical record review during observed visit, there was no evidence in the record of an EOB or current POC. Corrected on site.