Every finding on record at Hearts Ease Hospice Inc

Upon patient record review 2 of 14 (Patient #2,9) 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 2: No evidence that a spiritual care assessment of the patient or family was completed. Chaplain services were declined at the time of admission. There is no evidence that the RN or the SW completed this part of the assessment. RN admission assessment included patient/CG faith tradition as Christian. COS Patient 9: No evidence that a spiritual care assessment of the patient or family was completed. Chaplain services were declined at the time of admission. There is no evidence that the RN or the SW completed this part of the assessment. RN admission assessment included patient/CG faith tradition as Christian. COS

Upon patient record review, 2 of 14 (Patient #1,2) 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. Patient 1: The volunteer visit orders included as needed visits without a frequency for those visits nor a routine visit frequency. Patient 2: The volunteer visit orders included as needed visits without a frequency for those visits nor a routine visit frequency.