Every finding on record at Ohana Hospice and Palliative Care, Inc.

Upon patient record review, 6 of 14 (Patients #1,2,4,11,12,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1,2,4,11,12,14: Did not have assessment for imminence of death in patient record.

Upon patient record review, 6 of 14 (Patients #3,4,6,7,8,10) 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 # 3: This patient had a wheel chair. This was not included on the Plan of Care. Corrected on site (COS). Patient #4: The record reflected this patient had a bed, oxygen concentrator, shower chair and wheelchair. These were not included on the Plan of Care. COS. Patient #6: The record reflected this patient had an O2 concentrator, commode and wheelchair. These were not included on the Plan of Care. COS. Patient #7: The record reflected this patient had an O2 concentrator. This was not included on the Plan of Care. COS Patient #8: The record reflected this patient had an O2 concentrator, shower chair/bench and wheelchair. These were not included on the Plan of Care. COS Patient #10: The record reflected this patient had a wheelchair. This was not included on the Plan of Care. COS

Upon patient client record review, 10 of 14 (Patients #2,3,4,7,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 • Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contact information • Patient Notification of Hospice Non-Covered Items, Services, and Drugs Addendum information in accordance with Patients #2,3,4,7,9,14: Did not have start of care date filled in the space provided on the Election Statement form. Patients #10,11,12: Did not have BFCC or Addendum information on Election Statement form. Patient #13: The Election statement indicated a start of care date on 3/30/24. However, the hospice EMR indicated start of care date 4/1/24.

Upon personnel record review, 1 of 1 applicable (Personnel #4) 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.) ·(C) Shampoo, sink, tub, and bed Personnel File #4: The competency for shampoo did not specify if it included shampoo at sink.