Every finding on record at Lotus Bloom Hospice, 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, #3: During home visit it was noted that English is not the primary language for patient. There is no evidence that patient rights and responsibilities were provided to patient in their primary language.

Upon patient record review, 1 of 14 (Patient #1) 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#1: During home visit family indicated patient taking Omega 3 daily. There is no evidence of this on the medication profile. This was corrected on site by updating the medication profile.

Upon patient record review, 1 of 14 (Patient #5) 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#5: The record indicates that patient refused spiritual services, however there is problems, goals, interventions on POC for spiritual needs. The spiritual coordinator documents no spiritual needs in initial assess. The plan of care updated in order to correct on site.

Upon patient record review, 1 of 14 (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: During home visit the family indicated that patient taking Omega 3 1 daily. There is no evidence of an order for this. In order to correct on site an order was put in with appropriate information.

Upon client record review, 2 of 14 (Patient #3,5) 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 record indicates lab orders given on 4/10/25 for A1C and CBC. There is no evidence in chart this was completed or of any results if they were done. The agency was able to call and get results and uploaded to the chart in order to correct on site. The nurse also entered a late note documenting her follow up with the MD and the patient. Patient#5: The record indicates lab orders given on 7/14/25 for CBC. There is no evidence in chart this was completed or any results if they were done. The agency was able to call and get results and uploaded to the chart in order to correct on site. The nurse also entered a late note documenting her follow up with the MD and the patient.

Upon patient client record review, 2 of 14 (Patient #1,#3) 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, #3: The POLST indicates patient/family selected attempt resuscitation/CPR. The form indicates that this election requires the full treatment option for section B. However, the patient/family selected selective treatment. This does not allow for intubation. In order to correct on site the agency went to patient homes and new forms obtained an filled out appropriately.