Every finding on record at Mensa Hospice Care, Inc

Upon patient record review, 2 of 14 (Patients #8 and 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. Patients #8 and #9: Bereavement risk assessments were not within 5-day of comprehensive assessment. The bereavement risk assessment was completed late on 10/4/23.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Nursing comprehensive indicated patient had cane however, the plan of care did not list this item.

Upon personnel record review, 1 of 14 (Personnel #8 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #8: The CHHA initial competency had verbal verification for urinal and ROM skills. These skills were not observed/demonstrated as required.

Upon patient client record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14: Agency had information regarding Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), However, did not have BFCC-QIO contact information provided on Election of Benefit.

Upon patient client record review, 1 of 14 (Patients #5) 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 #5: Aide VF identified 2x week starting on 6/18/23 on POC, This date preceded start date of 7/23/23. COS.