Every finding on record at Lz Hospice Care Inc

Upon patient record review, 1 of 14 (Patient #9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 9: The medical record did not contain documented evidence of an RN visit between the dates of 07/13/25 and the present date of 08/12/25.

Upon patient record review, 2 of 14 (Patient #2, 6) 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 indicates the use of Divalproex and Levetiracetam for a known seizure disorder. The plan of care contained no evidence of the initiation or care planning of seizure precautions for patient safety. Patient 6: The MSW had a visit frequency of monthly with documentation at the last visit on 07/17/25 recording, "The patient appeared alert during the session but emotionally subdued, describing persistent sadness, fatigue, and low motivation tied to the progression of his illness." Also, " the MSW provided therapeutic support through active listening and life review interventions...coping strategies were touched, focusing on structured routines, mental stimulation, and maintaining social interaction." Finally, "monthly sessions planned to monitor emotional health and adapt support strategies as the patient condition evolves." There was no evidence of psychosocial problems, interventions, or goals found on the plan of care to reflect patient/family goals and interventions based on the problems identified in the MSW assessment.

Upon patient record review, 2 of 5 records (Patients #2, #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 2: Order dated 8/3/2022 is for Metformin 1000mg one tab 2x day oral for DM. In SOC assess under Endocrine it is marked "no Problem". DM is not mentioned in the diagnosis for this pt. There was no evidence in the POC for Altered Endocrine/DM with problem statement and or interventions. Corrected on site. Patient 4: On SOC complete order for O2 exists. The pts terminal diagnosis is End Stage COPD. There was no evidence of Oxygen Therapy/safety In the POC with problem statement or interventions.