Every finding on record at Lifespark Hospice, LLC

Upon patient record review 2 of 19 (Patient #3,12) 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 #3: Patient admitted 03/31/26. A psychosocial comprehensive assessment was not completed until 05/11/26. Patient #12: Patient admitted on 01/27/26. A psychosocial comprehensive assessment was not completed until 02/19/26.

Upon patient record review 1 of 19 (Patient #2) 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 #2: Patient admitted on 03/25/26. There is no evidence that a Comprehensive psychosocial assessment was completed within 5 days.

Upon patient record review, 2 of 19 (Patient #4,6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#4: Current medication profile includes Acetaminophen 975mg 3x daily scheduled and Acetaminophen 1000mg daily prn. There is no evidence of when the prn dose can be taken. Patient#6: Current medication profile includes orders for Lidocaine topical patch, orders do not include a site of application; Tylenol 1000mg twice daily and Tylenol 1000mg twice daily prn, order does not include not to exceed 4g within 24 hours in any form.

Upon patient record review, 2 of 19 (Patient #3,4) 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 #3: Patient admitted 03/31/26. There was no evidence that a bereavement assessment was completed within 5 days. Patient #4: Patient admitted 01/12/26. There was no evidence that a bereavement assessment was completed within 5 days.

Upon patient record review, 5 of 19 (Patient #1,3,7,9,13) 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 #1,7,9,13: Current medication orders include aspirin. The is no evidence of a risk for bleeding care plan. Patient #3: Current medication orders include Prednisone. There is no evidence of a risk for bleeding care plan.

Upon patient record review, 2 of 19 (Patient #4,6) 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 #4: Current POC includes Acetaminophen 975mg 3x daily scheduled and Acetaminophen 1000mg daily prn. There is no evidence of when the prn dose can be taken. Patient#6: Current POC includes orders for Lidocaine topical patch, orders do not include a site of application; Tylenol 1000mg twice daily and Tylenol 1000mg twice daily prn, order does not include not to exceed 4g within 24 hours in any form.

Upon patient record review 1 of 19 (Patient #4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #4: Aide supervisory visit was completed on 04/28/26 and not again until 05/13/26.

Upon patient record review, 6 of 19 (Patients #1,#6,#10,#11,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 1: The medication profile contained Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medication profile contained polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medical record contained nursing documentation upon recertification visit 5/24/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 11: The medication profile contained oxygen with no defined delivery method for administration. Corrected on site. Patient 13: The medication profile contained oxygen with no defined delivery method for administration. Corrected on site. Patient 14: The medication profile contained oxygen with no defined delivery method for administration. Corrected on site.

Upon patient record review, 3 of 19 (Patients #4,#12,#14) 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 4: The initial bereavement assessment was completed 2/15/23 with start of care 2/6/23. Patient 12: The initial bereavement assessment was completed 3/7/23 with start of care 2/28/23. Patient 14: The initial bereavement assessment was completed 6/19/23 with start of care 6/12/23.

Upon patient record review, 11 of 19 (Patients #2,#3,#4,#5,#6,#7,#8,#10,#12,#13,#14) 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 2: The medical record contained social worker documentation 5/9/23 identifying patient's son expressed concern with finances and potential need to complete Medicaid application. There was no evidence of problems, goals, and interventions related to financial concern and need for assistance. Patient 3: The plan of care contained an active problem of pain/altered comfort. There was no evidence of goals and interventions related to the problem. Patient 4: The plan of care contained an active problem of pain/altered comfort. There was no evidence of goals and interventions related to the problem. Patient 5: The medical record contained nursing documentation upon recertification visit 5/24/23 identifying patient was a risk for falls and skin impairment. There was no evidence of problems, goals, and interventions related to falls and skin. The plan of care also contained active problems of altered gastrointestinal function and potential for constipation. There was no evidence of goals and interventions related to gastrointestinal function. Patient 6: The plan of care contained active problems of altered skin integrity and need for wound care. There was no evidence of goals and interventions related to skin impairment or wounds. Patient 7: The plan of care contained active problems of altered gastrointestinal function and potential for constipation. There was no evidence of goals and interventions related to gastrointestinal function. Patient 8: The plan of care contained active problems of altered gastrointestinal function and pain/altered comfort. There was no evidence of goals and interventions related to gastrointestinal function and pain. Patient 10: The plan of care contained active problems identifying need for social work, spiritual care and home health aide services. The patient was not receiving any of these services. Patient 12: The plan of care contained active problems of need for social work and spiritual care services, and active problems, goals, and interventions related to spiritual care. The patient was not receiving social work and spiritual care visits. Patient 13: The medical record contained an ordered spiritual care frequency of twice monthly visits. There was no evidence of problems, goals, and interventions related to spiritual care. Patient 14: The plan of care contained an active problem of altered cardiopulmonary status and was witnessed with dyspnea at rest during home visit observation. There was no evidence of goals and intervention related to pulmonary/respiratory status.

Upon patient record review, 2 of 19 (Patient #3,#12) 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 3: The medical record contained ordered frequencies for social work 2Q2M2, 1M2 and spiritual care 2Q2M2, 2M1,1M1. The agency was unable to interpret definition of 2Q2M2 to decipher frequency needed. Corrected on site. Patient 12: The medical record contained ordered social work frequency of 3 PRN visits. There was no evidence of scheduled social work services.

Upon patient record review, 7 of 19 (Patients #1,#6,#9,#10,#11,#13,#14) 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 medical record contained an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medical record contained an order for polyethylene oral powder with no instructions for a diluent. Corrected on site. Patient 9: The medical record contained wound care orders 4/3/23 and 6/5/23 with no location of wounds identified. Corrected on site. Patient 10: The medical record contained nursing documentation upon recertification visit 5/24/23 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 11: The medical record contained an order for oxygen with no defined delivery method for administration. Corrected on site. Patient 13: The medical record contained an order for oxygen with no defined delivery method for administration. Corrected on site. Patient 14: The medical record contained an order for oxygen with no defined delivery method for administration. Corrected on site.

Upon patient record review, 8 of 19 (Patients #2,#5,#6,#7,#8,#10,#11,#14) 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 equipment and supply needs. Patient 2: The medical record contained nursing documentation upon recertification visit 3/29/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon recertification visit 5/24/23 identifying patient use of a Broda chair and the aide care plan contained instructions to use facility shower chair. There was no evidence of the Broda chair and shower chairs included as DME on the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon recertification visit 5/26/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 5/18/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon recertification visit 5/24/23 identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of the walker and wheelchair included as DME on the plan of care. Corrected on site. Patient 14: Upon observation during home visit, the patient utilized oxygen, hospital bed with rails, and wheelchair. There was no evidence of the oxygen concentrator and supplies, bed, rails, and wheelchair included as DME on the plan of care.

Upon client record review, 1 of 19 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained LPN documentation 5/22/23 stating wounds were assessed and determined that dressing not required because they were healed. There was no evidence of the wound care discontinued and the record contained RN documentation 5/26/23 stating dressing changes were completed.

Upon patient record review, 5 of 19 (Patients #2,#3,#9,#13,#14) 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 2: The medical record contained nursing documentation upon recertification visit 3/29/23 identifying patient was a 2 person pivot transfer. There was no evidence of transfer instructions included on the aide care plan. Corrected on site. Patient 3: The medical record contained nursing documentation 5/31/23 identifying patient required hand holding guidance for balance with ambulation. There was no evidence of transfer instructions included on the aide care plan. Patient 9: The medical record contained nursing documentation 6/1/23 identifying patient changed from stand by assist with ambulation to need for a mechanical lift. The current aide care plan stated stand by assist with ambulation and was not updated to reflect the change in transfer needs. Corrected on site. Patient 13: The medical record contained an order for patient to have continuous oxygen. There was no evidence of instructions for oxygen included in the aide care plan. Corrected on site. Patient 14: The medical record contained an order for patient to have continuous oxygen. There was no evidence of instructions for oxygen included in the aide care plan. Corrected on site.

Upon patient record review 1 of 19 (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: The medical record contained aide documentation stating spa bath given 5/26/23 and 6/2/23. There was no evidence of a task for a tub bath included on the aide care plan. The bathing task was for a shower.

Upon patient record review 2 of 19 (Patients #2,#3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2: There was no evidence of a nursing supervisory visit completed between 5/20/23 and review of record 6/20/23. Patient 3: There was no evidence of a nursing supervisory visit completed between 4/14/23 and 6/20/23.

Upon personnel record review, 1 of 14 (Personnel # 11 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 11: There was no evidence the employee received orientation.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 9: There was no evidence a verbal certification was received from the attending physician within two days of admission.

Upon patient client record review, 1 of 19 (Patient #10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 10: The medical record contained an election form identifying patient choice to receive the Notification of Hospice Non-Covered Items. There was no evidence the patient received the addendum.