Every finding on record at Glenmark Nursing Care Services Inc.

Upon patient record review, 1 of 14 (Patient #13) 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 #13: There was no record of Initial Bereavement Risk Assessment completed.

Upon patient record review, 4 of 14 (Patients #6,7,8,10) 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 Patients #6, 7, 8: The MSW visit frequency of, "Every Recert and as needed." This frequency did not identify the amount of PRN visits ordered. Patient #10: The SN visit frequency of, "1X week and as needed." This frequency did not identify the amount of PRN visits ordered.

Upon patient record review, 3 of 14 (Patients #1,2,3) 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. Patients #1,2,3: These patients all had a wheelchairs. These were not included on the Plan of Care. Corrected on Site.

Upon client record review, 2 of 14 (Patients #2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The POC listed Skilled Nursing visit frequency of, 2 X's per week (10/5/24). For first Benefit Week there was only 1 visit on 10/5/24. Patient #3: The POC listed Skilled Nursing visit frequency of, 2 X's per week (10/5/24). For first Benefit Week there was only 1 visit on 10/5/24.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • 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: There was no record of Bereavement Plan of Care in patients record. Agency did have evidence that letters were being sent.

Upon personnel record review, 1 of 13 (Personnel #9 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Normal range of motion and positioning Personnel #9: Did not have evidence on skill competency for Range of Motion was assessed.

Upon patient record review 6 of 14 (Patients #1,4,5,6,7,9) 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 (POC) Patient #1:The POC listed Aide visit frequency of, 2 X's per week (8/17/24). For the first Benefit Week there were no visits performed by the Aide. Patient #4:The POC listed Aide visit frequency of, 2 X's per week (5/2/24). For the first Benefit Week there were no visits performed by the Aide. Patient #5:The POC listed Aide visit frequency of, 2 X's per week (4/3/24). For the first Benefit Week there was one visit on 7/5/24 only. Patient #6:The POC listed Aide visit frequency of, 2 X's per week (6/5/24). For the first Benefit Week there were no visits performed by the Aide. Patient #7:The POC listed Aide visit frequency of, 2 X's per week (6/5/24). For the first Benefit Week there was one visit on 6/7/24 only. Patient #9:The POC listed Aide visit frequency of, 2 X's per week (6/13/24). For the first Benefit Week there were no visits performed by the Aide.

Upon patient record review, 1 of 14 (Patient #5) 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 Patient #5: The written certification did not include related diagnosis, only primary listed as Alzheimer Disease.

Upon client record review, 2 of 14 (Patients #11,12) did not have evidence that the discharge summary (DC) includes all required information. Patients #11,12: The DC summary did not include patients current plan of care