Every finding on record at Norris Hospice, Inc.

Upon patient record review, 5 of 15 (Patient #6, 9, 10, 11, 12) 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 #6 - SOC 09/08/23 - bereavement assessment completed 09/20/23. Patient #9 - SOC 09/08/23 - bereavement assessment completed 09/20/23. Patient #10 - SOC 09/06/23 - bereavement assessment completed 09/20/23. Patient #11 - SOC 05/26/23 - bereavement assessment completed 09/15/23. Patient #12- SOC 03/27/23 - bereavement assessment completed 08/18/23.

Upon patient record review, 1 of 15 (Patient #10) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #10 - Comprehensive assessment completed by the RN on 10/19/23 then not again until 11/15/23.

Upon patient record review, 3 of 15 (Patient #9, 11, 12) 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. Patient #9 - SC frequency POC 09/08/23 - 1 visit then PRN. Patient #11 - SC frequency POC 10/23/23 - 1 visit then PRN. Patient #12 - SC and MSW frequency POC 09/23/23 - PRN.

Upon client record review, 4 of 15 (Patient #10, 11, 13, 15) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #10 - IDG 09/22/23 then not again until 10/20/23. Patient #11 - IDG 09/22/23 then not again until 10/20/23. Patient #13 - IDG 09/22/23 then not again until 10/20/23. Patient #15 - IDG 09/22/23 then not again until 10/20/23.

Upon patient record review, 2 of 15 (Patient #1, 2) 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 #1 - Patient death on 03/12/23 - Bereavement POC developed sympathy card sent 03/13/23, 1 month letter sent 04/28/23 then no documentation regarding 3 month or 6 month letter being mailed per POC. Patient #2 - Patient death 05/06/23 - no evidence that bereavement POC developed or documentation that services were refused.

Upon patient record review 2 of 15 (Patient #7, 15) 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 #7 - Aide supervisory visit complete on 08/14/23 then not again through discharge on 09/29/23. Patient #15 - Aide supervisory visit 10/26/23 then again on 11/23/23.

Upon client record review, 1 of 15 (Patient #12) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #12 - POC 09/09/23 did not specify which if hospice or SNF would be responsible for g-tube site care.