Every finding on record at Hearten Hospice Care Inc.

Upon patient record review 1 of 13 (Patient #11) 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 #11: The initial spiritual assessment was performed on 2/27/21; the patient was admitted on 1/18/21.

Upon patient record review 1 of 13 (Patient #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 #13: There was no spiritual assessment completed on this patient.

Upon patient record review, 2 of 13 (Patients #5 and #11) 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 #5: The initial bereavement risk assessment was performed on 11/2/22; the patient was admitted on 7/1/22. Patient #11: The initial bereavement risk assessment was performed on 2/27/21; the patient was admitted on 1/18/21.

Upon patient record review, 7 of 13 (Patients #2, 3, 6, 7, 8, 12 and 13) 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. Patients #2 #3, #6 and #12: Admission orders for SC 1x mo and PRN and MSW PRN. The PRN frequency was not quantified for SC or MSW. Additionally, MSW has no baseline scheduled visits. Patients #7, #8, and #13: Admission orders for MSW was PRN. The PRN was not quantified and there was no baseline scheduled visits for this discipline.

Upon patient record review, 1 of 13 (Patient #1) 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 #1: The record reflected that this patient had a walker. This item was not included on Plan of Care.

Upon client record review, 2 of 13 (Patients #2 and #7) 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 Spiritual Counselor visit frequency of 1X per month. For the month of December there were no visits made by SC. Patient #7: The POC listed Spiritual Counselor visit frequency of 1X per month. For the months February and March there were no visits made by SC.

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: Patient #9: Toileting and elimination was a verbal competency performed by the aide not an observational task as required.

Upon patient record review 1 of 13 (Patient #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 Patient #9: The POC listed Aide visit frequency of 2 X's per week as ordered on 4/29/21. There was only 1 visit on 4/29/21 this week.

Upon patient client record review, 6 of 13 (Patients #2, 3, 8, 9, 11 and 12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #2, 3, 8, 9, 11 and 12: The agency used an old Election of Benefit form that does not include the following: (1) Patient Notification of Hospice Non Covered Items, (2) Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) information. The agency did create an addendum for this. However, there was initial of patient/family only. This addendum did not include signature line or date of when the form was executed.

Upon patient client record review, 2 of 13 (Patients #2 and #7) 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. Patients #2 & #7: CTI is not dated in space provided on form, next to physician signature.