Every finding on record at Pampered Hospice Care Inc

Upon patient record review, 6 of 14 (Patient #4,6,7,8,9,12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4,6,8, No evidence of psych social care plan addressed full code status. Patient #7, No evidence of psych social care plan addressed no mortuary addressed on initial assessment. Patient #9,12, No evidence of initial spiritual or psychosocial care plans. No evidence full code status addressed.

Upon patient record review, 1 of 14 (Patient #3) 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, No evidence of shower chair documented on plan of care. RN initial assessment documented shower chair as DME.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,2,4,5,6,9,10,11,13, The MSW visits were incomplete as evidenced by all notes had only date and time documented. Patient #1, MSW frequency every certification. Visit notes dated 12/5/23, 3/2/24, 5/31/24, all completed as telephone visits. No evidence of order for telephone visits. Patient #2, MSW frequency every certification. Visit on 3/29/24 completed as telephone visit. No evidence of order for telephone visits. Patient #3, MSW ordered to see patient every recertification but did not make visit to see patient. No evidence of visit made. Patient #4, MSW frequency 1x/month, visit on 4/30/24, completed as telephone visit. No evidence of order for telephone visits. Patient #5, MSW frequency every certification, visit on 4/21/24 completed as telephone visit. No evidence of order for telephone visits. Patient #6, MSW frequency every certification, visit on 3/7/24 completed as telephone visit. No evidence of order for telephone visits. Patient #7, MSW frequency every certification, visit on 12/9/23 completed as telephone visit. No evidence of order for telephone visits. Patient #8, MSW frequency every certification, visit on 9/27/23, 12/26/23, 3/26/24 completed as telephone visit. No evidence of order for telephone visits. Patient #9, MSW frequency every certification, visit on 9/5/23, 12/3/23, 3/3/24 completed as telephone visit. No evidence of order for telephone visits. Patient #10, MSW frequency every certification, visit on 7/11/23, 10/6/23, 3/4/24 completed as telephone visit. No evidence of order for telephone visits. Patient #11, MSW ordered to see patient every recertification but did not make visit to see patient. No evidence of visit made. Patient #12, MSW frequency every certification, visit on 7/1/23 completed as telephone visit. No evidence of order for telephone visits. Patient #13, MSW frequency every certification, visit on completed as telephone visit. No evidence of order for telephone visits

Upon patient record review, 3 of 14 (Patient #6,10,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6,10,14, Care plan directed vitals every visit. No evidence of parameters of vital signs.