Every finding on record at Eternity Hospice and Palliative Care, LLC

Upon patient record review 1 of 14 (Patient # 1) 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 # 1: Patient did not have evidence of a spiritual assessment completed as part of the comprehensive assessment.

Upon patient record review, 1 of 14 (Patient #1) 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 # 1: Patient did not have evidence of a bereavement assessment completed as part of the comprehensive assessment.

Upon patient record review, 3 of 14 (Patients # 1, 2, 3) 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: Upon home visit patient was using boost, heel protectors, hospital bed, over the bed table, briefs, wipes and gloves. These items where not listed on current plan of care dated 5/18/26. Patient # 2: Upon home visit patient was using an O2 cannister and concentrator, hospital bed, briefs, wipes, gloves, moisture barrier pads and a floor pad. These items where not listed on the current plan of care dated 5/18/26. Patient # 3: Upon home visit patient was using an O2 cannister and concentrator, hospital bed, briefs, wipes, gloves and a floor pad. These items where not listed on the current plan of care dated 5/18/26.

Upon patient client record review, 6 of 14 (Patients # 1, 2, 4, 6, 8, 9) 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 Patients # 1, 2, 4, 6, 8, 9: The patients' Election of Hospice benefits did not contain evidence of the effective date of the election. This line was left blank on the form.

Upon patient record review, 1 of 15 (Patient #2) 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. Wound care supplies for the Stage 4 Sacral Pressure which has a physician order for 3 times a week of wound care, were not included in the plan of care for this patient. In addition the hospice was not providing wound care supplies to the facility.

Upon personnel record review, 1 of 15 (Personnel #5) did not have evidence in the personnel file that the aide was evaluated while performing the tasks with a patient or pseudo patient as stated in 42 CFR 418.76(3)(b).

Upon personnel record review, 2 of 15 (Personnel #12 & 13) did not have evidence that credentialing activities were conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements.

Upon personnel record review, 5 of 15 (Personnel #10,11,12,13,&14) did not have evidence of criminal background checks obtained within three months of the date of employment or even after for all states that the individual has lived or worked in the past 3 years.

Upon personnel record review, 10 of 15 (Personnel #1,2,3,4,5,6,7,8,9 &15) did not have evidence of criminal background checks obtained within three months of the date of employment or even after for all states that the individual has lived or worked in the past 3 years.

Upon personnel record review, 2 of 15 (Personnel #7 & 8) did not have evidence that all personnel have been fully vaccinated for COVID-19. In addition, hospice agency has 27 personnel and only 23 had documented evidence of vaccine status, there was no evidence of vaccination status for Personnel 7 and 8 and two additional personnel (four total personnel not on the tracking logs).