Every finding on record at Crown Care Hospice Inc

Upon patient record review, 2 of 14 (Patient #3,#6) 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 and 6: The medical record does not contain evidence that an initial bereavement risk assessment was completed within 5 days.

Upon patient record review, 1 of 14 (Patient #4) 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 medications and treatments. Patient 4:The medical record contains documentation on 12/26/23 of wounds located on the left lateral malleolus and left distal1 toe with notation that the medical director was notified and a treatment order obtained. the plan of care includes an order to cleanse wounds with wound cleanser, pat dry, apply Bacitracin ointment cover with dry dressing twice daily x 14 days. There is no evidence in the order as to who is to perform treatment.

Upon patient record review, 2 of 14 (Patient #7,#9) 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 #7: The medical record contains documentation of a new stage II pressure ulcer to the left hip. The Skin Integumentary problem statement includes wounds of nephrostomy incision and stage II R flank wound. There is no evidence on the plan of care that the problem goals and interventions were updated to include L hip pressure ulcer. Patient #9:The medical record contains nursing documentation of a discontinuation of treatment to right heel wound due current status per assessment. There is no evidence on the plan of care that the problem, goals and interventions for skin integumentary were updated based on the updated comprehensive assessment.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13: Within the medical record, there is no evidence of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery.

Upon patient record review 2 of 14 (Patient #1,#3) 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:The medical record includes a aide plan of care developed on 12/26/23. Within the Plan of care there is an order for the frequency of visits to be provided 2 times weekly. There is only 1 visit documented on the week of 12/26/23 with no evidence of documentation to support the missed visit. Patient 3:The medical record includes a aide plan of care developed on 11/29/23. The POC has tasks assigned and an ordered frequency of aide visits of 2 times weekly. There is no documentation in the record to support completion of any visits and no documentation that the orders was discontinued or that patient refused visits.

Upon patient client record review, 14 of 14 (Patient #1-14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1-14: The medical record includes an election statement that does not include evidence of verbiage noting the patients right to receive in writing all hospice non covered items services and drugs.