Every finding on record at Elysian Hospice Houston, LLC

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient Visit 1, 2: The RN was observed wearing name badge with agency name, but there was no agency provided photo identification of the clinician.

Upon patient record review, 2 of 20 (Patient #10, 12) 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 #10: SOC 6/21/23. Bereavement assessment 7/11/23. Patient #12: SOC 8/29/23. Bereavement assessment 9/13/23.

Upon patient record review, 2 of 20 (Patient #4, 8) 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 #4: 8/17/23 POC -Admitted with indwelling Foley. IDG Plan of Care does not include related Problem/Interventions/Goals Patient #8: UTI 8/10/23. IDG Plan of Care not updated with related Problem/Interventions/Goals

Upon patient record review 1 of 20 (Patient #1) 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: 8/3/23 Aide Care plan included assignment to change linens first visit each week. Linens changed every visit 8/28, 8/30, 9/1/23, 9/5, 9/6, 9/9/23

Upon patient client record review, 17 of 20 (Patient #2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19) 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. Patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19 Consent lists all disciplines with checkbox for disciplines patient accepts. Also includes space to identify status of patient Advanced Directives - whether patient does/does not have in place and if/if not will provide copy. All options are left blank. However, information is provided elsewhere in record.

Upon client record review, 3 of 20 (Patient #15, 16, 20) did not have evidence that the discharge summary includes all required information. Patient 15, 16, 20: Discharge summaries do not include summary of patient's stay, including treatments, symptoms and pain management.