Every finding on record at Emerald First Choice Hospice, LLC

Upon patient record review, 1 of 19 (Patient #2) 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: The initial bereavement assessment was not completed within the 5 days of SOC. This assessment was completed on 1/5/23 (SOC 12/30/22).

Upon patient record review, 3 of 19 (Patients #1,2,4) 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 equipment and supply needs. Patient #1: This patient had a shower chair and wheel chair. These were not included on the Plan of Care. Corrected on site. Patient #2: This patient had a shower chair. This was not included on the Plan of Care. Corrected on site Patient #4: This patient had a hospital bed, bedside table and wheel chair cushion. These were not included on the Plan of Care. Corrected on site.

Upon patient record review, 1 of 19 (Patients #9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #9: The aide and facility staff provide care simultaneously to patient for ADL's each visit. The Plan of care indicates complete assist/total dependence, not max assist x2.

Upon patient record review 1 of 14 (Patient #2) 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 #2: Hospice sends two aides provide care to patient each visit. The plan of care nor order do not indicate sending two aides.

Upon patient client record review, 3 of 19 (Patients #1,2,3) 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 #1, 2 and 3: The hospice agency staff did not include credential following name on patients admitting consents and election statement.