Every finding on record at Deluxe Hospice Care

Upon patient record review, 2 of 14 (Patient # 5, 11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 5: The initial nursing assessment dated 09/25/25 recorded the use of oxygen PRN. The "Teaching Needs" section of the assessment further indicated oxygen as a teaching need. There was no documented evidence of oxygen provision, problems, interventions, goals or physician orders contained in the plan of care. Patient 11: The initial nursing assessment dated 09/05/25 recorded the use of oxygen as needed. The narrative further recorded education performed related to oxygen safety. There are no problems, interventions, goals or physician orders present on the plan of care associated with the need for or use of oxygen.

Upon contract review, 1 of 4 (Alternate Medical Director contract) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. The contract for Heidi Regenass, MD executed on 02/01/25 contains the title, "Medical Director" as does the contract executed for Philip Zhou, MD on 02/01/25. The organizational chart, Governing Body meeting minutes, and staff report indicate Heidi Regenass, MD is the Medical Director with Dr. Philip Zhou serving as designee. Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees. Corrected on site.