Every finding on record at Hospice of Gentle Care Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#1,#2,#7:During home visit it was indicated that the primary language for patient and family is Armenian. There is no evidence that the Patient's Rights and Responsibilities were provided in their language in writing.

Upon patient record review, 2 of 11 (Patient #3,#9) 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#3: The record indicates there is an order for aspiration precautions per physician order on 6/4/25. There is no evidence of Problems with goals and interventions related to this. This was corrected on site by updating plan of care to reflect this need. Patient#9: The record indicates patient requires aspiration precautions per physician order on admit. There is no evidence on plan of care of problem with goals or interventions related to this need. This was corrected on site by updating plan of care to reflect this need.

Upon client record review, 2 of 11 (Patient #3,#4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#3: The order on 6/13/25 indicates LVN frequency is 1 time per week. There is no evidence of an LVN visit the week of 6/16/25, or 7/20 Patient#4: The order on 5/5/25 indicates LVN visit 1 time per week. There is no evidence of a visit week of 6/1/25, 7/6, 7/20.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There is no evidence of documentation of any cost savings achieved through use of volunteers.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There is no evidence of documentation of the use of volunteers providing services during 2024 or 2025.

Upon patient client record review, 3 of 11 (Patient #1,#3,#4) 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#1: The record indicates the patient elected resuscitation/CPR however, they also chose selected treatment in section B. The form indicates only full treatment can be selected if patient chooses resuscitation/CPR. Patient#3,#4:The patient signed POLST selecting attempt CPR. However, in section B both full treatment and select treatment were selected. I am unable to identify which is correct. There is initials outside the selective treatment box but nothing to note is this indicates patient is or is not selecting this.