Every finding on record at Merced Hospice, Inc

Upon patient record review 1 of 19 (Patient #8) 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 #8 The initial Spiritual Comprehensive assessment dated 6/7/25, documented, "unable to locate patient". No assessments completed. (The Nursing comprehensive screening section for Bereavement marked as "none" for patient and caregiver. The Spiritual section documented, "Not active" in Faith. The "distress" area stated, "difficult to assess" and marked "yes" to Spiritual care visit. )

Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4 Caregiver verified Metformin 500mg po twice daily. Med profile and plan of care stated "Metformin 500mg po daily". Upon surveyor return to agency, reported to DPCS whom will clarify and Reconcile.

Upon patient record review, 1 of 19 (Patient #8) 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 #8 The Bereavement Risk Assessment assessment dated 6/7/25, documented, "unable to locate patient". No assessments completed.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #17 Passed 5/19/25. The Post Death Assessment dated 5/29/25 stated, "I called primary bereaved multiple times with no response. Left voicemail offering support. I am marking as a decline due to being unable to reach." There was no documentation of any further contact.

Upon personnel record review, 1 of 16 (Personnel #6 ) 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.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Patient #6 Competency included "Bath in tub/shower" did not include "Sponge" bath. "Shampoo" did not designate demonstration in "sink, tub, and bed".

Upon patient record review, 3 of 6 records (Patient #2,#4,#6) 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: The medical record contained nursing documentation upon admission identifying patient use of wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Patient 6: The medical record contained an order for oxygen. There was no evidence of the oxygen supplies and equipment included on the plan of care.

Upon patient client record review, 1 of 6 records (Patient #6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated. Patient 6: The medical record contained four aide visits the week of 5/22/22 confirmed by leadership as data entry error. Leadership inquiry discovered aide entered visit in with the wrong date and entered a second visit when unable to correct.