Every finding on record at Maluhia Hospice Care PLLC

Upon client record review, 1 of 14 (Patient #7) did not contain evidence that the IDG ensured that the care and services were being provided in accordance with the plan of care: Patient #7: Initial POC dated 5/15/25 reflected that both the Chaplain and MSW were to make visits on a frequency of 1x/month and this was followed. The IDG dated 5/28/25 reflected that the Chaplain and MSW were to make visits one time weekly each and this plan was not correct. DON made correction to the IDG record to reflect 1x/month while on site.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence in the patient record that the hospice aide POC/assignment sheets and duties indicated what tasks are to be done by the Aide, to include any of the other individualized/pertinent patient information: Patient #7: the initial Aide POC (dated 5/15/25) did not reflect that the patient had an order for oxygen.

Upon patient record review 1 of 9 (Patient #7) 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 #7 - SOC 06/02/2022 - psychosocial assessment completed on 06/11/2022.

Upon patient record review 1 of 3 applicable (Patient #9) 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 #9 - Aide visit frequency 3 x week, aide only provided 1 visit the first week.

Upon patient client record review, 1 of 9 (Patient #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 #3 - SN visit note on 06/28/2022, 07/01/2022 and 07/10/2022 contained "wound care performed" Nurse did not document specific wound care.