Every finding on record at Exceptional Hospice Care

Upon observation and home visits 1 of 3 (Patient #10), 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 #10 - Upon entering the patient's home for the home visit, the chaplain showed his name badge for identification purposes, however it had another hospice agency name attached.

Upon patient record review 1 of 14 (Patient #3) 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 #3 - The medical record showed an MSW comprehensive note dated 03/16/26 noting the patient refused the MSW. This note was documented and signed by the RN. Neither this note or the nursing comprehensive assessment note contained the elements of a comprehensive psychosocial assessment.

Upon patient record review, 1 of 14 (Patient #3) 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 #3 - Patient was admitted to hospice on 03/16/25. There was no evidence that an initial bereavement assessment was completed.

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 medical record showed an order dated 03/11/26 for an x-ray of the patients right knee related to swelling. The medical record showed nurse visits on 03/16/26, 03/19/26 and 03/25/26 with no documentation of any follow up.

Upon patient record review, 2 of 14 (Patient #2,9) 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 #2 - The advanced directives showed patient wished to remain a full code. The plan of care showed no evidence of problems, goals, or interventions related to the full code status. The nursing comprehensive dated 06/04/25, documented patient was on a mechanical soft diet. There was no evidence of problems, goals, or interventions related to that diet. Patient #9 - The medication profile contained ASA 81 mg daily as a blood thinner. There was no evidence of problems, goals, or interventions related to bleeding risk.

Upon patient record review, 5 of 14 (Patient #1,4,9,11,14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1 - The medical record showed an order dated 12/09/25 for spiritual care and social work visits "1 time for evaluation and as needed." There was no evidence of frequency for the as needed visits. Patient #4 - The frequency order for MSW and Chaplain visits dated 02/27/26 states frequency to be "1 visit and then prn." There was no evidence of the number of visits for the prn frequency. Patient #9 - The frequency order for MSW and Chaplain visits dated 04/05/26 states frequency to be "1 time for evaluation and then as needed." There was no evidence of the number of visits for the as needed frequency. Patient #11 - The medical record showed an order dated 11/04/25 for "MSW visits one time and then prn." There was no evidence of a frequency for those prn visits. Patient #14 - The frequency order for MSW and Chaplain visits dated 03/20/26 states frequency to be "1 time for evaluation and then as needed." There was no evidence of the number of visits for the as needed frequency.

Upon client record review, 2 of 14 (Patient #2,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 - The medical record showed an order dated 03/11/26 for an x-ray of the patients right knee related to swelling. There was no evidence that this x-ray was obtained. Patient #8 - The medical record showed an order dated 09/22/25 for spiritual care visits one time per month. There was no evidence of a visit for the month of April 2026 and no missed visit documentation.

Upon observation and home visit 1 of 3 (Patient #10), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #10 - During the home visit, the chaplain brought a violin in a violin case along with a speaker in a backpack. He placed both items on the floor of the Board and Care facility without a barrier.

Upon patient record review, 1 of 14 (Patient #7) 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 #7 - The medical record showed an order dated 04/30/26 to decrease aide visits to one visit per week. The aide plan of care was not updated to show this new frequency order. The plan of care still showed a frequency of three times per week.

Upon patient record review 1 of 14 (Patient #7) 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 #7 - The medical record showed an order dated 08/19/25 for aide frequency of visits at three times per week. For the weeks of April 6, April 13, and April 20, there was evidence of only 1 visit per week for those weeks.

Upon patient client record review, 6 of 14 (Patient #1,3,5,8,10,12) 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 Patient #1,3,5,8,10,12 - The election of benefit form contained a section on page 1 of 8, with patient's right to chose an attending physician. On all patients, both choices - "I do not wish to choose an attending physician" and "I acknowledge that my choice for an attending physician is" were marked. Below that section, the Medical Director's name was entered.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency for the skilled nurse was indicated at 1x/week x 12 weeks. There was no evidence of any nursing visit for the week of 3/26/23 to 4/1/23.