Every finding on record at Empire Hospice Care, Inc.

Upon patient record review, 3 of 11 (Patient #6,8,11) 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 #6, SC Evaluation ordered at SOC. SC documented patient refused SC services without completing assessment. Missing evidence any member of the IDG completed the spiritual assessment. Patient #8, #11 SC declined by patient. Missing evidence any member of the IDG completed the spiritual assessment.

Upon patient record review, 11 of 11 (Patient #1,2,3,4,5,6,7,8,9,10,11) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon client record review, 7 of 11 (Patient #1,3,4,5,6,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SN frequency 1x/week. Patient seen on 2/28/22, 3/2/22 and 3/3/22 without order for additional visits. Patient #3, SN frequency 1x/week. LVN seen patient weekly with RN every other week without order for visit. Patient #4, SN frequency 2x/week. Week of 2/27/22 patient seen 2x by LVN and 1x by RN without order for extra visit. Patient #5, SN frequency 1x/week. LVN is making weekly visits with RN reassess every 2 weeks. There is missing evidence of orders for the additional RN visit. Patient #6, SN frequency 2x/week. LVN is making visits 2x/week with RN reassess every 2 weeks. There is missing evidence of orders for the additional RN visit. Patient #7, SN frequency 2x/week. LVN is making visits 2x/week with RN reassess every 2 weeks. There is missing evidence of orders for the additional RN visit. Patient #8, SN frequency 2x/week. LVN is making visits 2x/week with RN reassess every 2 weeks. There is missing evidence of orders for the additional RN visit.

Upon patient record review 2 of 9 applicable (Patient #2,3) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #2, Aide care plan states to perform, bed bath, shampoo, comb hair, oral care, skin care, peri care, nail care, assist with transfers, ROM, ambulation every visit, Aide note 1/3/22 did not complete shower, skin care, comb hair or nail care per Aide POC. Note 1/8/22, did not complete peri care, nail care, shampoo, skin care per Aide POC. Note 1/5/22, did not complete bed bath, comb hair, peri care, ROM, skin care per Aide POC. 1/17/22 did not complete bed bath, comb hair, peri care, nail care, skin care per Aide POC. 1/19/22 did not complete bed bath or comp hair was not documented, peri care, nail care, ROM and skin care not completed per Aide POC. Additionally, aide ordered 2x/week. Patient seen only 1x week of 1/9/22, 2/20/22 and 2/27/22. Patient had no visits week of 1/23/22, 1/30/22, 2/6/22, and 2/20/22. Patient #3, Aide care plan states to perform shower, shampoo, comb hair, oral care, peri care, nail care, position up in chair, ambulate and assist with transfer. Aide note on 2/9/22 did not document completion of ambulation per Aide POC.

Upon patient client record review, 8 of 11 (Patient #3,4,5,6,7,8,9,11) 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. Patient #3, IDG notes from 11/19/21,1/28/22 and 2/9/22 did not have signature from SC. Patient #4, IDG note from 2/25/22 only had RN signature, missing MSW, SC, MD signatures. Patient #5, IDG note from 2/23/22 only signed by RN, missing MSW, SC, MD signatures. Patient #6, IDG note form 1/14/22 only signed by MD, missing MSW, SC, RN signatures, 2/11/22 and 2/23/22 note, only RN signature, missing MSW, SC, MD signatures. Additionally, missing patient signature on forms Right to Choose Attending MD and Hospice coverage. There was a compliant consent and election statement to address the items. Patient #7, IDG note 2/11/22 and 2/23/22, only MSW signature, missing RN, MD, SC. Admission order on 2/1/22 did not have signature from MD. Patient #8, IDG note 11/5/21 no documentation from MSW, SC, only MD signature, missing RN, SC, MSW. 2/11/22 and 2/23/22 note, no documentation from MSW or SC, missing SC signature. Admission order on 9/24/21 did not have signature from MD. Patient #9, Admission order on 9/24/21 did not have signature from MD. Patient #11 Missing patient signature on forms Right to Choose Attending MD and Hospice coverage. There was a compliant consent and election statement to address the items.