Every finding on record at Hospice at Lsmnj Inc.

Upon patient record review, 3 of 9 (Patient #1, 2, 3) 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: CM (Case Manager) 1 visits weekly and 8 prn every 30 days. SC 1 visit monthly 6 prn every 30 days. Vol 1 visit weekly and 8 prn every 30 days. Patient #2: CM (Case Manager) 1 visits weekly and 8 prn every 30 days. MSW 1 monthly 4 prn every 30 days. SC 1 visit monthly 4 prn every 30 days. Patient #3: CM (Case Manager) 3 visits weekly and 8 prn every 30 days. SC and MSW 1 visit every 30 days and 8 prn every 30 days. Education provided regarding use of CM term vs SN/Nursing. PRN frequencies too broad. Education regarding specific scope of frequency and indication for adjust frequency as indicated by patient change in condition rather than broad quantity of PRN visits.

Upon client record review, 1 of 9 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: SOC 10/18/23 with initial frequency for SC 1/month. There is no documented visit for November.

Upon patient record review 1 of 9 (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 Patient #4: HA assignment includes task of tub/shower. 9/8/23 note, there is a line drawn through the box rather than a check or "refuse". It is not clear, as documented that task was complete and/or if patient refused.