Every finding on record at Hillcrest Hospice LLC

Upon patient record review 1 of 19 (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 patient was admitted on 2/14/24. MSW comprehensive assessment completed on 2/21/24,

Upon patient record review 5 of 19 (Patient #5,6,7,8,10) 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 #5,6,7,8,10, there was no evidence of a spiritual care assessment of the patient or family. Chaplain services were denied. There is no evidence the RN completed this part of the assessment.

Upon patient record review, 17 of 19 (Patient #1,2,3,4,5,6,7,9,10,11,12,13,14,15,16,17,18) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2,3,4,5,6,7,9,10,11,12,13,14,15,16,17,18, No evidence of need for personal care added to plan of care.

Upon patient record review, 17 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17) 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17, MSW frequency 3 PRN for patient and family needs. No evidence of scheduled frequency after evaluation completed. Patient #12, Volunteer frequency PRN 12 visits, no evidence of scope and frequency is too high

Upon patient record review, 17 of 19 (Patient #1,2,3,4,5,6,7,9,10,11,12,13,14,15,16,17,18) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1,2,3,4,5,6,7,9,10,11,12,13,14,15,16,17,18, frequency included 3 PRN for personal cares. Patient #13, Aide care plan identifies left lower leg wound, no evidence of directions for aide on for covering wound for bed bath.

Upon patient client record review, 2 of 19 (Patient #5,6) 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 #5,6, No evidence of identifying if patient has Advanced Directive, yes or no check box left empty.

Upon client record review, 2 of 17 (Patient #15,16) did not have evidence that the discharge summary includes all required information. Patient #15,16, No evidence of discharge summary completed. Discharge summary was faxed with summary left empty.

Upon client record review, 5 of 19 (Patient #12, 13, 17, 18, 19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #12, Nurses note on 2/29/24 documents patient arms are contracted requiring 1:1 feeding, ordered LALM and bolster. No evidence problems/goals/interventions updated on POC. In addition, MSW frequency 3 PRN for patient/family need, MSW visit made on 3/7/24 for MSW transition visit to introduce new MSW as PRN visit, no evidence of patient/family need. Volunteer frequency PRN 12 visits, visit 3/25/24 pet therapy. Patient #13, Nurses note on 3/18/24 documents wound care stopped to left shin as it is completely healed. No evidence problems/goals/interventions updated on POC. In addition, No evidence of wound measurements weekly per plan of care on 3/11/24 or 3/13/24. Care plan intervention states facility staff needs to demonstrate before completing wound care, no evidence intervention was met. Patient #17,18,19, No evidence problems/goals/interventions updated on POC with actively dying.