Every finding on record at Freedom Life Hospice LLC

Upon patient record review 2 of 14 (Patient #2, 4) 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 02: The patient was admitted on 7/14/24 with a primary diagnosis of intrahepatic bile duct carcinoma. Upon home visit, it is witnessed that the patient has ascites and a biliary drain is in place to his upper left abdominal quadrant, the initial RN assessment does not include information, measurements or identification of the ascites or the biliary drain. Patient 04: The patient was admitted on 6/14/24, there is no evidence of a psychosocial assessment completed to date.

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 01: The patient was admitted on 7/4/24, the bereaved individual on initial assessment is noted to be the patients wife, upon home visit it was identified that the patients wife passed away approx 1 year ago as verbalized by the patient and his brother. There was no evidence the bereavement assessment identified the next of kin who would be impacted by the patient's death and lack of evidence a bereavement assessment was completed incorporating the next of kin.

Upon patient record review, 3 of 14 (Patient #1, 7, 13) 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 01: The patients wife is reported to have passed away approx 1 year ago, the patient expresses grief related to the loss of his wife, the plan of care does not include a problem statement with interventions and goals for bereavement care. Patient 07: The patient was admitted on 1/23/23 with a primary diagnosis of hypertensive heart disease with heart failure and is prescribed Eliquis 2.5mg PO twice daily, the plan of care does not include instructions and interventions for bleeding precautions. Patient 13: The patient was admitted on 5/12/23 with a primary diagnosis of hypertensive heart disease with heart failure and is prescribed Clopidogrel 75mg daily, the plan of care does not include bleeding precautions.

Upon patient client record review, 1 of 14 (Patient #4) 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 04: The patient was admitted on 6/14/24, the initial plan of care has not been signed, dated and authenticated by the hospice medical director.