Every finding on record at Friendship Hospice Inc

Upon patient record review, 1 of 14 (Patient #2) 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 2: RN initial assessment 2/11/23 documentation reflects the answer to, "BC visit indicated?" as "yes" further stating in comments, "For initial assessment, will be done within 5 day period" No evidence of pt refusal or completion of assessment by any other discipline. Initial bereavement assessment completed 8/9/23.

Upon client record review, 1 of 14 (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: Initial MSW assessment on 2/25/24 was conducted by telephone. There is no evidence of this request by pt/cg or that this is needed or required for this patient. The POC does not indicate the physician has approved telephonic or virtual visits.

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. Volunteer savings report dated 1/1/23-1/1/24 equals 4.37% of total patient care hours.

Upon patient client record review, 1 of 14 (Patient #5) 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 #5: Patient elected to receive the notice of Hospice Non-covered Items upon admission (12/26/23). The patient declined the notice of non-coverage on the Election Statement but did indicate on the Informed Consent that they wished to be furnished the Notice of Non-covered Items. There is no documentation of discussion to clarify pt. wishes. There is no evidence that the form was provided to the patient.