Every finding on record at Orange County Hospice Services Inc.

Upon client record review, 3 of 14 (Patient # 1, 5 & 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 there was not a Spiritual care eval and Social work visits provided in accordance with the the Plan of Care dated 9/08/23 that included SC 1x month and MSW to start 9/06/23 for 3 visits. Patient #5 there was not a Spiritual care visit provided in accordance with the the Plan of Care dated 1/25/23 that included SC 1 x month for 3 month to begin on 1/26/23. Patient #10 there was not a Social work visit provided in accordance with the the Plan of Care dated 8/15/23 that included MSW 1 x month for 2 months to begin on 8/15/23. Wound care was not performed on SN visits 4/14/23 and 4/18/23which were included as an active order for the Stage 2 Pressure Sore on the L buttocks area every SN visit.

Upon personnel record review, 6 of 16 (Personnel #4,6,7,9, 10 & 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon observation and record reviews, there was no evidence the hospice designated a physician to serve as alternate Medical Director that when the Medical Director is not available, a physician designated by the hospice will assumes the same responsibilities and obligations as the Medical Director.

Upon client record review, 1 of 14 (Patient #12) the transfer summary was not forwarded to the the facility when patient was transferred and the copy of the patient record which had an evidence of request sent by the facility to the HSP agency.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that a copy of the hospice discharge summary and the patient's clinical record if requested, was forwarded to the attending physician when the patient revoked the election of hospice care and was discharged from hospice in accordance with §418.26.

Upon personnel record review, 1 of 16 (Personnel #2) did not have evidence that personnel credentialing activities were conducted to verify qualification in the position through primary source verification at the time of hire in accordance with specific state practice act requirements.