Every finding on record at Ease in Hospice Care Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#1,#2,#3: The primary language of patient was not English. This was verified during home visit and there is no evidence in home or chart that patient/family received patient rights and responsibilities written in patient primary language.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: During home visit it was noted that diclofenac sodium 1% and cephalexin was present in the home and patient is currently using. However, there is no evidence of these medication on medication profile. Corrected on site,

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#2: The record indicates patient had an open wound to right great toe on 5/8/25. There is no evidence of measurements or description of size of wound from 5/8 to present made by the RN.

Upon patient record review, 4 of 14 (Patient #1,#4,#5,#10) 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#1: The record indicates there is a physician order stating patient requires aspiration precautions, fall precautions, skin precautions, bleeding precautions, and diabetic foot protocol. Also, the admit RN documents that patient requires epilepsy precautions. There is no evidence of problems with goals or interventions related to these issues. Corrected on site. Patient#4: The record contains a physician order stating patient requires skin precautions, aspiration precautions, oxygen safety measures, and diabetic foot protocol. There is no evidence of problems with goals or interventions related to these issues. Corrected on site. Patient#5: The record contains a physician order stating patient requires fall precautions, skin precautions, and bleeding precautions. There is no evidence of problems with goals or interventions related to these issues. The patient is also receiving spiritual services, however there are no problems, goals, or interventions related to these services. Corrected on site. Patient#10: The record contains a physician order stating patient requires oxygen precautions, skin precautions, aspiration precautions, and bleeding precautions. There is no evidence of problems with goals or interventions related to these issues. The patient is also receiving spiritual services, however there are no problems, goals, or interventions related to these services. Corrected on site.

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 medications and treatments. Patient#9: RN documentation indicates patient is on a regular consistency diet with NAS. There is no evidence of order for NAS. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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#1: During home visit it was noted that patient has hospital bed, 1/2 rails, and over the bed table. There is no evidence of an order for these items on plan of care. Corrected on site.

Upon client record review, 6 of 14 (Patient #1,#2,#3,#6,#7,#8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient#1: The record indicates IDG was held on 4/30/25 and 4/24. There is no evidence of any narrative of documentation on progress toward goals from social worker or spiritual coordinator. Patient#2: : The record indicates IDG was held in 4/30/25 and 4/26. There is no evidence of narrative or documentation on progress toward goals from MSW or from SC for this IDG Patient#3: The record indicates IDG was held in 4/30/25. There is no evidence of narrative or documentation on progress toward goals from MSW for this IDG. Also for IDG 4/16, 4/2, 3/19, and 3/5 there is no evidence of narrative or documentation on progress toward goals from SC for these IDG's. Patient#6,#7,#8: The record indicates IDG was held in 4/30/25, 4/16, 4/2, and 3/19. There is no evidence of narrative or documentation on progress toward goals from SC for these IDG.

Upon patient client record review, 2 of 14 (Patient #3,#7) 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#3: Upon review of the record it was evident that RN visits on 4/9/25, 4/25, and 5/10 were copied and pasted. There was no evidence of appropriate authentication based on individual events of each visit. Patient#7: The record indicates the Aide services were declined at admit. However, The RN completed an aide plan of care on 2/14/25 and 2/17. The RN also completed aide supervisory visit on 2/27 that listed the name of an aide. There is no evidence in the chart that the aide ever completed or was assigned an aide visit.