Every finding on record at Journey Palliative and Hospice, Inc

Upon patient record review, 1 of 14 (Patient #12) 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. #12-No Initial Bereavement Assessment was documented in the patient record.

Upon patient record review 1 of 14 (Patient #10) 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 #10-Aide Plan of Care assigned vital signs to be taken at each aide visit. No vital signs were documented on any of the aide visits throughout the patient records, as per POC.

Upon observation, there was no evidence of a contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 4 of 5 (Patient #1,2,3 & 4) did not have evidence that all appliances, durable medical equipment, related to the palliation and management of the terminal illness and related conditions used in the management of the patient's end of life care needs are included in the plan of care. Patient # 1 Plan of Care did not include the walker and cane that was assessed and documented in the comprehensive nursing assessment dated 1-17-2022 Patient # 2 Plan of Care did not include the walker that was assessed and documented in the nursing comprehensive assessment dated 1-01-2022 Patient # 3 Plan of Care did not include the wheelchair that was assessed and documented in the nursing comprehensive assessment dated 2-06-2022 Patient # 4 Plan of Care did not include the cane that was assessed and documented in the nursing comprehensive assessment dated -2-04-2022

Upon client record review, 2 of 2 applicable (Patient #1&2) did not have evidence that upon discharge from the hospice, a copy of the discharge summary is sent to the patient's attending MD.

Upon client record review, 2 of 2 applicable (Patient #1 & 2) did not have evidence the discharge summary included the following: • A summary of the patient's stay, including treatments, symptoms and pain management • Any other documentation that will assist in post-discharge continuity of care