Every finding on record at Medicus Community Care Hospice

Upon patient record review, 4 of 14 (Patient #5,7,8,9) 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 #5,7,8,9, No evidence of bereavement assessment was completed. Assessment was blank. Patient #8, No evidence of bereavement assessment was completed. Documented "declined" as the reason assessment was not completed.

Upon patient record review, 5 of 14 (Patient #1,5,6,7,9) 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 #1,5,6,7,9, MSW initial assessment did not document funeral home. No evidence of plan for no funeral home addressed on plan of care.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #9, No evidence of MSW and SC documented on IDG form dated 12/6/24. No evidence of RN signature on IDG dated on 12/6/24 and 2/14/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signatures/documentation to validate participation.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, LVN did not place a barrier between his nursing bag and floor. Patient #2, LVN did not place a barrier between his nursing bag and dresser. Patient #3, LVN did not place a barrier between his nursing bag and chair. LVN washed hands, placed rubber gloves on hands then looked at patient right foot. LVN removed gloves and donned new gloves. No evidence of washing hands between changing of gloves.

Upon patient record review, 2 of 5 (Patient #2 and #3) 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 This patient had a over the bed table (OBT) and wheel chair. These were not included on the Plan of Care. The agency obtained an order on 4-7-22 to include/update these items on POC. Patient #3 This patient had a hospital bed, OBT and shower chair. These were not included on the Plan of Care. The agency obtained an order on 4-7-22 to include/update these items on POC.

Upon client record review, 1 of 5 (Patient #3) 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 POC listed Skilled Nursing visit frequency of, 2 X's per week. For Benefit Week 3/27/22 there was only 1 visit on 4/1/22 which was the admission/SOC date. The visit frequency of 2 X's per week was not met.