Every finding on record at Mega Hospice Services Inc

Upon patient record review 6 of 14 (Patient #1, 5, 6, 8, 9, 10) 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 1, 5, 6, 8, 9, 10: There was no evidence that the patients' psychosocial needs were addressed as a part of the comprehensive assessment. During the initial comprehensive nursing assessments, the skilled nurse noted that the patients required further assessment by a medical social worker to determine needs; however, there was no evidence of follow up visits for ongoing assessment.

Upon patient record review, 9 of 14 (Patient #1, 2, 4, 5, 6, 7, 8, 9, 10) 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 1, 2, 3, 4, 5, 6, 7, 8, 9, 10: There was no evidence of an initial bereavement assessment completed within 5 days of the hospice admission, or at any subsequent time.

Upon client record review, 6 of 14 (Patient #4, 5, 6, 7, 8, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: MSW and SC visits were ordered for 1 x monthly; however, there was no evidence that either discipline made any follow up visits with the patient. Patient 5: SC visits were ordered for 1 x monthly; however, there was no evidence that the chaplain made a follow up visit with the patient during the months of March or April 2023. Patient 6: MSW and SC visits were ordered for 1 x monthly; however, there was no evidence that either discipline made any follow up visits with the patient. Patient 7: MSW and SC visits were ordered for 1 x monthly; however, there was no evidence that either discipline made any follow up visits with the patient. Additionally, SN visits were ordered for 1 x weekly; however, there was no evidence that a nurse made a follow up visit with the patient during the week of 04.16.2023. Patient 8: SN visits were ordered for 1 x weekly; however, there was no evidence that a nurse made a follow up visit with the patient during the week of 04.02.2023. Patient 10: SN visits were ordered for 1 x weekly; however, there was no evidence that a nurse made a follow up visit with the patient during the week of 04.16.2023 and two nursing visits were made during the week of 04.23.2023, on 04.23.2023 and 04.29.2023.

Upon patient record review 1 of 14 (Patient #5) 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 5: Aide visits were ordered for 1 x weekly, with 1 PRN visit; however, there was evidence that a Aide has only visited the patient twice during the hospice admission, on 12.21.2022 and 01.20.2023. Additionally, Aide visits may not be ordered on a PRN basis. (HA care plan and discipline orders corrected onsite)

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements Personnel 6: Per the job description, the administrator and alternate must be either a MD, a RN, or have 2 years of supervisory experience in a healthcare setting; there is no evidence the Alternate Administrator meets this requirement. He does have extensive supervisory experience in other industries.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 4: At the time of hospice admission, the patient/caregiver requested a copy of the Notification of Noncovered Services; however, there was no evidence that this form was returned to the patient/family within 5 days, or at any subsequent time.