Every finding on record at Good Life Palliative Care

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Records indicate on Medicare Election Form patient signed with no Choice of Attending listed .

Upon patient record review 7 of 14 (Patient #1, #5, #6, #8, #9, #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. Patient #1: Record indicates that Initial Spiritual Assessment 1/19/24 is blank with no signature and no evidence of assessment completed by any discipline within 5 days of admission. Patient #5: Record indicates that Initial Spiritual Assessment 10/22/22 assessment is blank with missing signature and no evidence of assessment completed by any discipline within 5 days of admission. Patient #6: Record indicates that Initial Psychosocial Assessment 7/27/23, assessment is blank and no evidence of assessment completed by any discipline within 5 days of admission. Patient #8: Record indicates that Initial Spiritual Assessment completed 06/10/22, is blank with missing signature. In addition, MSW Psychosocial Assessment is blank with only signature. No evidence of either assessment completed by any discipline within 5 days of admission. Patient #9: Record indicates there is no evidence of Spiritual Assessment 1/10/23 is blank and missing signature and no evidence of assessment completed by any discipline within 5 days of admission. Patient #10: Record indicates there is no evidence of Spiritual Assessment or Psychosocial Assessment completed within the 5 calendar day by and no evidence of assessment completed by any discipline within 5 days of admission. Patient #11: Record indicates that Initial Spiritual Assessment 10/05/22 is blank and missing signature and no evidence of assessment completed by any discipline within 5 days of admission.

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: No evidence of a bereavement assessment after admission.

Upon patient client record review, 1 of 14 (Patient #1) 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 #1: Records indicate on Medicare Election Form patient signed with no Agency signature, date or Choice of Attending listed .

Upon patient client record review, 7 of 14 (Patient #2, #3, #4, #7, #10, #11, #14) 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 #2: Record indicates that Initial Spiritual Assessment completed 3/27/23 is missing Chaplain signature. Patient #3: Record indicates that Initial Spiritual Assessment completed 8/5/23 is missing Chaplain signature. Patient #4: Record indicates that Initial Spiritual Assessment completed 8/18/23 is missing Chaplain signature. In addition to no signed date next to Physician signature. Patient #7: Record indicates that Initial Spiritual Assessment completed 5/05/23 is missing Chaplain signature. Patient #10: Record indicates that Initial Psychosocial Assessment completed 6/03/22 is missing signature. In addition to, no evidence of RN signature and date Recertification Plan of care on 8/30/22, 1/27/23, 3/28/23, and 5/27/23. Patient#11: End of Care Summary is blank on 5/11/23. Patient #14: Records indicate the initial Bereavement Assessment completed on 6/19/23 with missing Patient Name, as well as the time in and out documentation.

Upon client record review, 1 of 14 (Patient # 11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11:Record indicates no evidence of Discharge Summary sent to the attending physician completed on 05/11/23 upon Patient revocation.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient#11: Record indicates no evidence of discharge summary completed upon Discharge on 05/11/23. Blank summary with no evidence of the patient's stay, including treatments, symptoms and pain management, current plan of care, patient's latest physician orders, and Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.