Every finding on record at Florence Hospice LLC

Upon patient record review 1 of 14 (Patient #5) 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 5: No evidence that a psychosocial assessment was completed within the first five days. Time stamp in the computer but no actual assessment entered or uploaded to EMR. Note completed by end of survey day 1.

Upon client record review, 6 of 14 (Patient #3,4,5,6,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: SOC has SN visits ordered weekly. No evidence that assessments are occurring weekly. Last documented visit was on 06/09. Computer time stamp says that the visits occurred weekly no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Patient 4: SOC has SN visits ordered weekly. No evidence that assessments are occurring weekly. Last documented visit was on 07/06. Computer time stamp says that the visits occurred weekly no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Patient 5: SOC has SN visits ordered weekly. No evidence that assessments are occurring weekly. Last documented visit was on 06/25. Computer time stamp says that the visits occurred weekly no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Communication notes were written on June 29th, July 6th, and July 15th, however no evidence that an assessment was completed. MSW order to evaluate patient on admit POC. Time stamp in the computer but no actual assessment entered or uploaded to EMR. Note completed by end of survey day 1. Patient 6: SOC has SN visits ordered weekly. No evidence that assessments are occurring weekly. Last documented visit was on 06/08. Computer time stamp says that the visits occurred weekly no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Patient 8: SOC has SN visits ordered weekly. No evidence that assessments are occurring weekly. Last documented visit was on 06/08. Computer time stamp says that the visits occurred weekly no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Patient 9: MD order on 04/25 for MSW to evaluate patient and help with food stamp process. Time stamp in the computer says that the visit was completed on 04/29 no assessment documentation entered in the computer or paper assessment uploaded to the chart at the start of survey. Documentation completed by the end of survey day 1. Agency policy is for documentation to be completed within 36 hours after the end of the visit. MSW made a follow phone call/televisit on 05/23. No evidence that an order was received before MSW made her visit.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13: Bereavement POC has letters to be sent out at the 1st month, 3rd month, 6th month, 9th month, 12th month, and 13 month. No evidence that letters were ever sent out, all letters remain in pending status. Patient 14: Bereavement POC has letters to be sent out at the 1st month, 3rd month, 6th month, 9th month, 12th month, and 13 month. No evidence that letters were ever sent out, all letters remain in pending status.

Upon patient record review 1 of 14 (Patient #6) 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 6 No evidence that aide visit on July 3rd and July 10th were documented at the time of survey. Computer time stamp entered on calendar.

Upon patient client record review, 1 of 14 (Patient #10) 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. Patient 10: IDG biweekly meeting updates being copied and pasted. IDG meeting notes from 2nd BP until last IDG meeting on 07/05 have SW and SC visits occurring once a week. SW nor SC on patients active POC. Corrected on site.