Every finding on record at Midas Healing Hospice, Inc

Upon patient record review, 5 of 16 (Patient #3,7,10,13,15) 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 #3,7,10,13,15 did not have evidence of an Initial Bereavement Risk assessment completed.

Upon patient record review, 1 of 16 (Patient #12) 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 #12 passed 03/19/24. Post death call and assessment completed by SCP with a narrative note of "will continue to support" and noted a condolence card mailed 03/22/24. There was not a Bereavement Plan of Care completed and no further evidence of any contact or mailings.

Upon patient client record review, 13 of 16 (Patient #3,4,5,7,8,9,10,11,12,13,14,15,16) 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 #3,4,5,7,8,9,10,11,12,13,14,15,16 did not have a date with the signatures on page 9. The Consents (election and the required information to be given) are 9 pages..the first page is actual "election" with a blank for patient name and date of election. No signatures required on pg1. Page 8 a blank space for the "to begin on" (SOC) date, no signature required. Page 9 are the check boxes to be marked for "acknowledgement of receipt of information" and the only page that requires Signatures for Patient / Patient Representative and date and the Hospice Representative. There are no dates with the signatures on page 9 for the listed 13 records. Patient #3 also had a POLST completed by daughter and hospice staff on admission 09/28/23. The Physician signed the POLST with a signature date of "03/12/1930" which was the patient's date of birth.