Every finding on record at Concierge Hospice Care

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 4: The patient was admitted on 12/26/25. The spiritual care comprehensive assessment was not completed until 01/02/26.

Upon patient record review, 2 of 14 (Patient #3,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 3: The patient was admitted on 08/11/25, the comprehensive assessment does not assess for imminence of death. Patient 10: The patient was admitted on 06/05/25, the comprehensive assessment does not assess for imminence of death.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The patient was admitted on 06/05/25, there is no evidence that a bereavement assessment has been completed.

Upon patient record review, 1 of 14 (Patient #9) 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 9: Walker indicated as DME required for ambulation and transfer on most recent Aide assignment dated 12/13/25. Most recent POC dated 1/19/26 does not indicate a walker as DME provided or used. Corrected on site, POC updated.

Upon patient record review, 5 of 14 (Patient #3,6,7,8,10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3: The POC dated 01/21/26 contains an order for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 6: Current POC dated 01/19/26 includes an order for Aspirin, there is no evidence of a risk for bleeding with appropriate goals and interventions. Corrected on site, POC updated. Patient 7: Current POC dated 01/19/26 includes an order for Aspirin, there is no evidence of a risk for bleeding with appropriate goals and interventions. Corrected on site, POC updated. Patient 8: RN visit note dated 1/15/26 notes “a small sore on (L) leg, the sore was cleaned , triple antibiotic was applied and covered with clean dressing.” There is no evidence of a skin integrity care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 10: The most recent POC dated 01/19/26 includes and order for Clopidogrel. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated.

Upon client record review, 3 of 14 (Patient #5,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Patient was admitted 12/13/25. Social work visit frequency is ordered weekly. Initial psychosocial was completed 12/16/25 and a SW visit is documented 01/20/26. There is no evidence to support weekly frequency. Patient 7: Current POC dated 01/19/26 includes orders for Spiritual care frequency of 1x weekly and 3prn. Visits documented for 11/19/25 & 01/22/26. There is no evidence that weekly visits were made and no missed visits noted. Patient 8: Visit note dated 1/15/26 notes “a small sore on (L) leg, the sore was cleaned , triple antibiotic was applied and covered with clean dressing.” There is no evidence of orders for wound care. Corrected on site, orders obtained.

Upon patient record review, 4 of 14 (Patient #1,2,4,9) 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 1: Most current POC does not include evidence of frequencies of tasks including: Encourage fluids as tolerated if not contraindicated and change patient linens. Corrected on site, POC updated. Patient 2: Most current Aide POC dated 10/30/25 does not include frequencies of tasks including: record bowel movement and dressing. Corrected on site, POC updated. Patient 4: Most current Aide POC dated 12/26/25 does not include frequencies of tasks including: dressing and change patient linens. Corrected on site, POC updated. Patient 9: Most current Aide POC dated 12/26/25 does not include frequencies of tasks including: turn and reposition, record bowel movements and dressing. Corrected on site, POC updated.

Upon patient record review 1 of 14 (Patient #1) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Most recent POC dated 01/21/26 includes orders for an Aide 3 times per week. There is no evidence that visits have been initiated.

Upon patient record review 1 of 11 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: The patient was admitted for hospice services on 01.03.2023; however, the comprehensive initial assessment related to spiritual care needs was not completed until 01.13.2023.

Upon patient record review, 2 of 11 (Patient #1, 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 1: The patient was admitted for hospice services on 01.03.2023; however, the initial bereavement assessment was not completed until 01.13.2023. Patient 3: The patient was admitted for hospice services on 12.23.2022; however, no initial bereavement assessment has been completed.

Upon patient record review, 2 of 11 (Patient #1, 9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days (21 days for the PHE waiver) Patient 1: The RN made a visit to the patient on 01.04.2023 during which a comprehensive assessment was performed and the patient's plan of care was updated. The next visit by the RN was not made until 01.30.2023, when another comprehensive assessment was performed and the patient's plan of care was updated. Patient 9: The RN made a visit to the patient on 10.26.2022 during which a comprehensive assessment was performed and the patient's plan of care was updated. The next visit by the RN was not made until 11.22.2022, when another comprehensive assessment was performed and the patient's plan of care was updated.

Upon patient record review, 3 of 11 (Patient #2, 3, 11) 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 patient requires the use of a hospital bed, OTB table, walker, wheelchair, and shower chair for management of the terminal illness; however, this DME does not appear on the patient's plan of care. (corrected onsite) Patient 3: The patient requires the use of a hospital bed, OTB table, and shower chair for management of the terminal illness; however, this DME does not appear on the patient's plan of care. (corrected onsite) Patient 11: The patient requires the use of a walker, scooter, oxygen, and nebulizer for management of the terminal illness; however, this DME does not appear on the patient's plan of care.

Upon client record review, 1 of 11 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: The patient had RN visits ordered for 1x monthly, with 3 PRN visits for symptom control. However, the RN made visits to the patient on August 03 and 10, 2022, then began making more frequent visits when the patient's death appeared imminent. The RN made a visit to the patient on 08.23, 2 visits to the patient on 08.25, and a visit to the patient on each day 08.26, 08.27, and 08.28, 2022.

Upon patient record review, 9 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 1, 2, 3, 4, 5, 6, 7, 8, 9: The hospice aide care plans, for tasks such as the patient's bath, hair care, and brushing the teeth, did not specify the frequency for the tasks ordered/being performed. (corrected onsite for all active patients)