Every finding on record at Glencare Hospice Services, Inc.

Upon patient record review 2 of 14 (Patient #5,6) 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. #5 - Spiritual Care assessment dated 07/20/22 was outside of the 5 day window. #6 - Psychosocial assessment date 07/01/24 was outside of the 5 day window.

Upon patient record review 4 of 14 (Patient #2,8,10,11) 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. #2-Spiritual assessment was not completed. #8-Spiritual assessment was not completed. #10-Spiritual assessment was not completed. #11-Spiritual assessment was not completed.

Upon patient record review, 7 of 14 (Patient #2,3,8,9,10,11,12) 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. There is no initial bereavement assessment for the referenced patients.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. #6-Wound care orders for left forearm and left lower extremity dated 6/26/24 state "reassess after 2 weeks." There is no follow up or additional orders noted in the chart. Wound care order for forehead date 07/07/24 state "reassess after 2 weeks." Nursing notes from 06/28,07/01,07/05 and 07/08 do not address the wounds.

Upon patient record review, 5 of 14 (Patient #1,2,3,4,6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. #1-MSW and SC are both ordered 1x month and prn - there is no frequency for PRN. #2-MSW is ordered 1x month and prn - there is no frequency for PRN. #3-MSW is ordered 1x month and prn - there is no frequency for PRN. #4-SC is ordered 1x month and prn -there is no frequency for PRN. #6-MSW is ordered for eval and prn - there is no frequency for PRN.

Upon client record review, 3 of 14 (Patient #1,2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #1-MSW and SC are both ordered 1x month and prn -No MSW visits made after eval. #2-MSW is ordered 1x month and prn - No MSW visits made after eval. #3-MSW is ordered 1x month and prn - No MSW visits made after eval.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patients 1&2 - Nurse put dirty equipment in bag and brought it back out to clean at the end of the visit.

Upon patient record review, 1 of 14 (Patient #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 #14-There is no evidence of a bereavement plan of care.

Upon patient record review 1 of 14 (Patient #10) 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 #10-CHHA visits order 2 x wk. No visits were made after 04/30/24 due to CHHA feeling unsafe. There is no evidence of an order to hold or discontinue visits.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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 All referenced records were missing reflection of the patient's individual clinical circumstances. No evidence the physician documented the patient's comprehensive medical information in order to compose this brief clinical justification narrative.

Upon patient record review, 4 of 14 (Patient #2,3,4,9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. #2 - Narrative dated 06/03/24 was missing reflection of the patient's individual clinical circumstances. No evidence the physician documented the patient's comprehensive medical information in order to compose this brief clinical justification narrative. #3 - Narrative dated 01/15/24 was missing reflection of the patient's individual clinical circumstances. No evidence the physician documented the patient's comprehensive medical information in order to compose this brief clinical justification narrative. #4 - Narrative dated 05/23/24 was missing reflection of the patient's individual clinical circumstances. No evidence the physician documented the patient's comprehensive medical information in order to compose this brief clinical justification narrative. #9 - Narrative dated 02/19/24 was missing reflection of the patient's individual clinical circumstances. No evidence the physician documented the patient's comprehensive medical information in order to compose this brief clinical justification narrative.

Upon patient client record review, 2 of 14 (Patient #8,11) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. #8-The initial CTI dated 01/14/24 is not signed by the attending MD. #11-The initial CTI dated 01/19/24 is not signed the the attending MD.