Every finding on record at Genuine Hospice Services Inc

Upon patient record review 1 of 14 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 02: The patient was admitted on 7/12/24, the record does not include an initial psychosocial assessment within 5 days of admission.

Upon patient record review 4 of 14 (Patient #9, 10, 12, 13) 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 09: The patient was admitted on 9/1/23, there is no evidence of a comprehensive psychosocial assessment performed by the MSW, RN or SC. Patient 10: The patient was admitted on 3/29/24, there is no evidence of a comprehensive psychosocial assessment performed by the MSW, RN or SC. Patient 12: The patient was admitted on 8/1/23, there is no evidence of a comprehensive psychosocial assessment performed by the MSW, RN or SC. Patient 13: The patient was admitted on 8/11/23, there is no evidence of a comprehensive psychosocial assessment performed by the MSW, RN or SC.

Upon patient record review, 2 of 14 (Patient #01, 04) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 01-The patient record indicates the start of a new benefit period on 7/16/24, the last IDG was documented on 7/4/24 with no evidence of subjective or objective recertification assessments included in the IDG notes. A registered nurse visit has not been documented since 6/19/24. Patient 04- There are no documented RN visits since the admission on 6/28/24.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 06: Documentation in the patient record on 6/14/24 indicates that the patient utilizes a wheelchair for mobility "at times." The wheelchair in not included in the plan of care for utilized DME.

Upon client record review, 4 of 14 (Patient #1, 3, 4, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 01: The plan of care includes frequency orders for RN visits Q14 days starting on 4/8/24, at the time of survey, the last documented RN visit occurred on 6/19/24. Patient 03: The patient was admitted on 11/24/23 in the first benefit period. The plan of care includes orders for MSW visits at each benefit period starting 11/24/23. The patient received a visit on 11/27/24 and 5/23/24, no visits were made during benefit period #2 for dates 2/22/24 - 5/21/24. Patient 04: The plan of care includes visit orders for the LVN for 1 time per week effective 6/28/24, the record includes documented visits on 7/3/24 and 7/17/24, there are no visit entered for the week of 7/14/24 - 7/20/24. Orders are entered for RN visits Q14 days, there are no documented RN visits since the admission on 6/28/24. Patient 05: The plan of care includes visit frequency orders for SN 1 time per week effective 5/20/24, no skilled nursing visits were made for the week of 6/16/24 - 6/22/24 or 6/30/24 - 7/6/24. There is no evidence of refused or declined visits.