Every finding on record at Heartful Hospice Care Inc

Upon patient record review 1 of 14 (Patient #4) 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. #4-There was no evidence of a Comprehensive Psychosocial assessment completed; there was documentation that Social Worker would complete within 5 days of SOC but it was not completed.

Upon patient record review, 3 of 14 (Patient #3, #6, #10) 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. #3-There was no evidence of a comprehensive bereavement assessment completed within 5 days. #6-There was no evidence of a comprehensive bereavement assessment completed within 5 days. #10-There was no evidence of a comprehensive bereavement assessment completed within 5 days.

Upon patient record review 1 of 14 (Patient #4) 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 #4-Per aide POC, aide to take vital signs each visit. No vital signs documented for visit notes dated 02/11/25 and 02/13/25.