Every finding on record at Jmj Hospice Care, Inc.

Upon patient record review 4 of 14 (Patient #3, 5, 7, 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 3: The comprehensive assessment failed to address the spiritual needs of the patient/family that are related to the terminal illness. Patient 5: The comprehensive assessment failed to address the spiritual needs of the patient/family that are related to the terminal illness. Patient 7: The comprehensive assessment failed to address the spiritual needs of the patient/family that are related to the terminal illness. Patient 10: The comprehensive assessment failed to address the spiritual or psychosocial needs of the patient/family that are related to the terminal illness.

Upon patient record review, 1 of 14 (Patient #4) 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 4: At the time of admission for hospice services, the patient was noted to be a moderate fall risk. The patient utilizes a walker for ambulation and also requires standby assist due to concern regarding fall risk. The patient also is noted to require complete assistance with all ADLs. On 09.02.2024, the patient was noted to have had a fall at home; this was also recorded in the hospice's QAPI plan. However, neither at the time of hospice admission. nor after the actual fall, has the IDT developed a safety care plan for this patient related to fall risk and associated home safety. (corrected onsite)

Upon patient record review, 2 of 14 (Patient #12, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 12, 14: There was no evidence that a bereavement care plan was developed or updated after the time of the patient's death.

Upon patient record review 3 of 5 (Patient #1, 3, 5) 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 1: The patient was admitted for hospice services on 10.07.2021; the comprehensive spiritual care assessment was not completed until 10.13.2021. Patient 3: The patient was admitted for hospice services on 07.22.2021; the comprehensive spiritual care assessment was not completed until 07.31.2021. Patient 5: The patient was admitted for hospice services on 01.15.2021; the comprehensive psychosocial assessment was not completed until 01.25.2021.

Upon patient record review 1 of 5 (Patient #5) 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: There was no evidence of a comprehensive spiritual assessment to determine needs needs related to the dying process.

Upon patient record review, 2 of 5 (Patient #1, 5) 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. Patient 1: The patient was admitted for hospice services on 10.07.2021; the comprehensive bereavement assessment was not completed until 10.13.2021. Patient 5: The patient was admitted for hospice services on 01.15.2021; the comprehensive bereavement assessment was not completed until 01.25.2021.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The patient utilizes a condom catheter for management of his terminal illness. Supplies are noted on the supply list, and the comprehensive initial assessment notes the presence of the catheter in the GU section. However, there is no evidence of signed treatment orders in the care plan related to the catheter. (corrected on site)

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1, 2, 3, 4, 5: The election statements are not updated to reflect the October 2020 updates which require patient/caregiver notification of noncovered services and related appeal to the BFCC-QIO.