Every finding on record at Compassionate Care Hospice of Lake and Sumter, Inc.

Upon patient record review, 6 of 23 (Patients #3, 4, 5, 6, 9, and 10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patients #3, 4, 5, 6, 9, and 10: For each of these patients, there was not a 'scope' of service included in their 07/02/24 IDG Plan(s) of Care, for their Physician-ordered Chaplain services.

Upon patient record review, 3 of 23 (Patients #4, 16, 17) did not contain evidence that the revised Plan of Care included all information from the patient's updated comprehensive assessment(s): Patient #4: During the 07/10/24 Surveyor-attended home visit, the RN discussed the presence of a left heel wound/pressure ulcer, and the weekly dressing changes being provided for such, "Cleanse with wound wash, apply skin barrier to peri-wound, then adhesive dressing. Every week and prn soiling." This wound intervention had originally been ordered on 05/18/24. However, such wound care intervention had not been updated to the most recent 07/02/24 IDG Plan of Care. Patient #16: SOC 05/07/24. The 05/15/24 SN visit note reflected that the patient was using compression stockings. This therapeutic treatment was not included on the Hospice Plan of Care. Patient #17: A Physician order was obtained on 05/15/24 for, "SN to insert 18F, 10cc Foley Catheter. Change every month, and p.r.n. pain/dislodgement." The most recent IDG POC dated 07/09/24, noted "Indwelling catheter in place." However, the full details of this ongoing intervention, was not included on the POC. Nor was there any information as to how, or by whom, such Foley was to be maintained/monitored.

Upon patient record review, 1 of 23 (Patient #17) did not contain evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #17: A Physician order was obtained on 05/15/24 for, "SN to insert 18F, 10cc Foley Catheter. (which was documented as inserted on 05/15/24) Change every month, and p.r.n. pain/dislodgement." There was no documented evidence within the clinical record of the Hospice having changed such Foley in the month of June 2024.

Upon patient record review, 1 of 23 (Patient #15) did not contain evidence that the IDG had documented the sharing of information between all disciplines providing care and services, in all settings, whether the care and services are provided directly or under arrangement. Patient #15: The 06/21/24 RN visit report noted a pulse rate of 140. There was no documentation of the Hospice nurse having reported this to the Hospice Physician.

Upon observation, there was not documented evidence of the Hospice's use of Volunteers providing day to day administrative and/or direct patient care services, in an amount that at a minimum, equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. The Administrator provided the 2023 calendar-year Volunteer report to Surveyor, which totaled 0.27%.

Upon patient record review, 1 of 23 (Patient #3) did not contain evidence that all entries were comprehensively completed in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #3: During the 07/10/24 Surveyor-attended home visit, the patient stated that the gauze bandage on his left lower shin had been placed by the Hospice nurse on 07/08/24. The record reflected a verbal order having been obtained 07/08/24 to, "Cleanse left lower leg, and apply gauze bandage". However, the nursing visit dated 07/08/24 did not include documentation of the application of such a dressing.