Every finding on record at Mgd Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: No evidence that the patient chose an attending at the time of admit. Attending section of election form left blank.

Upon patient record review 1 of 14 (Patient #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 10: No evidence that an initial psychosocial assessment. RN answered "yes" that a MSW visit was needed/requested. Initial plan of care has MSW visit ordered to evaluate the patient however, there was no evidence of follow up.

Upon patient record review, 1 of 14 (Patient #7) 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 7: No evidence that bereavement risk assessment was completed within 5 days after admit. Bereavement risk assessment completed on 7/18/2023. Patient was admitted on 01/17/2023.

Upon patient record review, 4 of 14 (Patient #1,2,3,4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients 1,2,3,4: Plan of care has PRN visit orders for LCSW. No evidence of routine visits or frequency for PRN visits on plan of care.

Upon client record review, 2 of 14 (Patient #10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: Initial plan of care has MSW visit ordered to evaluate the patient however, there was no evidence of follow up visit. Patient 11: MSW plan of care frequency set at once monthly. No evidence that a MSW visit was completed for the month of October.

Upon patient record review 1 of 14 (Patient #6) 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 6: HHA plan of care frequency set at twice weekly. No evidence that 2 aide visits occurred for the week of 06/11/2023.

Upon patient record review 2 of 14 (Patient #2,6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2: No evidence that an on-site supervised visit was made every 14 days. Missed supervised visit for the aide between 10/25/2023 and 11/22/2023. Patient 6: No evidence that an on-site supervised visit was made every 14 days. Missed supervised visit for the aide between 06/04/2023 and 06/25/2023.

Upon patient client record review, 2 of 14 (Patient #1,3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1: No evidence that the patient chose an attending at the time of admit. Attending section of election form left blank. Patient 3: No evidence that an effective date was listed on election statement as this was left blank.

Upon patient client record review, 1 of 14 (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: No evidence that Informed consent form or election statement was signed by a hospice agent.