Every finding on record at Devine Hospice Care, Inc.

Upon patient record review, 12 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13: There is a separate form for patient to choose attending physician, a choice is made, but there is no patient or representative signature validation.

Upon patient record review 2 of 14 (Patient #1, 2) 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. SOC 3/23/23 spiritual assessment not completed until day Day 9 (4/1/23). Patient #2 SOC 6/6/23 spiritual assessment not completed until 6/16/23.

Upon patient record review 9 of 14 (Patient #3, 4, 6, 7, 8, 9, 10, 11, 13) 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. Patient #3, 4, 6, 7, 9, 13 No evidence of initial spiritual assessment. Patient #8, 10, 11 No evidence of initial psychosocial or spiritual assessment.

Upon patient record review, 4 of 14 (Patient #2, 4, 8, 14) 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 #2, 4, 8, 14: There is no initial bereavement assessment on file within 5 days of SOC.

Upon client record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 3/23/23. Initial frequency order SN 2x/mo, MSW 1/mo, SC 1/mo for 3 months starting 3/23/23. SN visits documented 5/2, 5/9, 5/26, 5/23, 5/30, 6/6, 6/13, 6/15/23. MSW frequency 1x mo for 3 months and then 3/25 order "MSW decline starting 5/23/23". 3/27 MSW initial assessment visit. 6/22/23 note with time 10a-11a, although there is a 6/23/23 note that MSW contacted patient and he declined. There was no SC visit for July. Patient #2: SOC 6/6/23. Initial order MSW 1/mo. Patient was only seen by MSW for initial assessment 6/10/23. There was a 6/30/23 communication note by MSW stating that patient's daughter had called requesting "MSW initial visit tomorrow". There is no July visit documented. Patient #3. SOC 2/21/23. Initial SN frequency 1/wk. SN provided 2/wk from March, through July; There was no update to frequency. MSW and SC frequency 1x/mo with 5/22/23 frequency order update. No visits made for either discipline May, June, July. Patient #4: SOC 5/20/23. Initial POC frequency orders SN 3x/wk. SN visits provided 2x/wk week of June 21 through July 7; SN visits provided 1x/wk July 23 and July 31. No updated orders POC frequency. Patient #5: SOC 1/23/23. Initial frequency for SC Eval. Freq updated 2/14/23 SC eval. SC visits provided monthly throughout admission. 4/23/23 order for MSW 1x/mo. MSW was not provided monthly (Only 1/27, 4/24, 7/23/23). Patient #6: SOC 5-2-23. SN frequency 2x/mo, but updated 5/9/23 to 1xwk. SN visits provided 2x/wk May 2 through July 25; MSW/SC Frequency updated 5/9/23 IDG for MSW 1/mo and continued same with 7/31-10/28/23 Only documented MSW visits were 5/4 and 8/1/23. Patient #7: SOC 6/5/23 Frequency is SN 1/WK. There was no LVN or RN visit week of 7/10/23. Patient #8: SOC 7/10/23 Freq SC/MSW 1/mo. No SC / MSW visits made at all. No updates to IDG POC thru 8/1/23. Patient #9: SOC 12/21/22 Initial IDG POC freq SC /MSW 1/mo. No SC Visits made at all. MSW visits 12/26/22, 3/22/23, 6/20/22 only. Patient #10: SOC 4/13/23 Freq SN 1/wk. SN visits made 2x/wk : May 7 through Aug 9. SC/MSW 1/month. No visits at all or communication notes by MSW. Only note for SC is July 3, 2023. No updates to IDG POC.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #5. Competency form addresses competency for Shampoo only. Does not specify sink, tub, bed.

Upon patient record review 1 of 13 (Patient #4) 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 #4 SOC 5/20/23 has order for HA 1/wk on POC and IDG POC from SOC thru 8/1/23 IDG. HA assignment sheet was completed SOC. However, there were no notes for any visits. Agency wrote clarification order 8/14/23 that HA was declined, to be effective 5/20-8/17/23.

Upon patient record review 1 of 13 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8: SOC 7/10/23 HA 1/week. RN notes 7/24 and 8/7/23 do not validate HA supervision - section is checked as not at this time.

Upon patient record review, 1 of 14 (Patient #9) 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. Patient #9: There is no evidence of narrative statement by MD to support patient eligibility for the benefit period beginning 6/19/23.

Upon patient client record review, 12 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13) 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, 3, 4, 7: Page 2 of 2 on Admission Agreement form including Hospice Election Effective date is blank. The second separate form Election of Medicare Hospice Benefit has date, but there is no space for patient acknowledgment or signature. Patient# 2, 5, 6, 8, 9, 10, 11, 13: Patient Consent for Primary Physician: There is a separate form with space for patient name and options for choosing attending physician and attending physician is identified, but there is no patient signature for acknowledgement.

Upon patient client record review, 1 of 14 (Patient #1) 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. Patient #1: Admission comprehensive assessment narrative references sacral wound and states cleaning and wound care done as ordered. There is no order for wound care. There is no further reference to the wound or wound care in subsequent notes, care plan or IDG. Most recent SN visit note filed is 7/25/23.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11, 12: There is no evidence that the discharge summary was sent to the attending physician.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patient #11: SOC 5/7/23. The discharge summary upon patient 5/22/23 revocation, does not include a comprehensive review of the hospice services provided, discharge instructions, individualized review of symptoms management while on hospice. Patient #11 summary states that patient received doctors visits, nurse visits, MSW visit, SC visits, medication, DME and supplies all while on hospice. In fact, the patient did not receive all services listed (MSW, SC). Patient #12; The discharge summary was general and not individualized to address symptom management during hospice admission. The patient was not recertified due to no decline in condition. There was no documented discharge planning or discharge orders or instructions in the discharge summary.