Every finding on record at Confidence & Care Hospice Inc.

Upon patient record review 1 of 14 (Patient #8) 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. #8-Spiritual assessment dated 07/23/24 was outside of 5 calendar days after the election of hospice care.

Upon patient record review 6 of 14 (Patient #2,3,9,10,13,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. #2,3,9,10,13,14- All referenced records are missing a spiritual assessment.

Upon patient record review, 11 of 14 (Patient #2,3,4,7,8,9,10,11,12,13,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness #2-CTI dated 1/26/24 states "patient meets LCD guidelines for hospice." No detail is given. #3-CTI dated 03/18/24 states "patient meets LCD guidelines for hospice." No detail is given. #4-CTIs dated 11/21/23 states"patient meets LCD guidelines for hospice." No detail is given. #7-CTI dated 04/24/24 states "patient meets LCD guidelines for hospice." No detail is given. #8-CTI dated 04/03/24 states "patient meets LCD guidelines for hospice." No detail is given. #9-CTI dated 02/01/24 states "patient meets LCD guidelines for hospice." No detail is given. #10-CTI dated 02/25/24 states "patient meets LCD guidelines for hospice." No detail is given. #11-CTI dated 06/11/24 states "patient meets LCD guidelines for hospice." No detail is given. #12-CTI dated 03/27/24 states "patient meets LCD guidelines for hospice." No detail is given. #13-CTI dated 01/25/24 states "patient meets LCD guidelines for hospice." No detail is given. #14-CTI dated 05/08/24 states "patient meets LCD guidelines for hospice." No detail is given.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. #4-Recertification CTI dated 05/12/24 states "patient meets LCD guidelines for hospice." No detail is given.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. All records were missing legible signatures with credentials on consent and admission paperwork.