Every finding on record at Ezra Hospice, Inc.

Upon patient record review 2 of 14 (Patient #3, 8) 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 03: The patient was admitted on 3/27/24, a spiritual assessment has not been completed to date. Patient 08: The patient was admitted on 3/29/24, a spiritual assessment has not been completed to date.

Upon patient record review, 1 of 14 (Patient #3) 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 03: The patient was admitted on 3/26/24 with a primary diagnosis of hypertensive heart disease with heart failure, the patient has a secondary condition of dementia and is assessed as being "confused" and the medication profile includes orders for Memantine 10mg daily, used for the treatment of mild to moderate dementia. The plan of care does not include a neurological problem statement with interventions and goals for the management of the dementia.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The hospice use of volunteers is not equal to 5% of the total patient care hours of all paid employees and contract personnel for 2023.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 03: The certificate of terminal illness for the benefit period starting on 3/27/24 is signed and completed by the medical director and does not include a written narrative that includes subjective and objective findings.