Every finding on record at Perpetual Help Hospice, Inc.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient 4: Consent and election effective dates 4/04/24. SOC and RN initial assessment was completed on 4/11/24.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 4: Consent and election effective dates 04/04/24. RN, MSW and SC completed the comprehensive assessment on 4/11/24.

Upon patient record review, 1 of 14 (Patient #4) 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 4: Consent and election effective dates 04/04/24. Bereavement assessment completed on 4/11/24.

Upon patient record review, 2 of 14 (Patient #2, 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 #2: Patient admitted 4/19/24 with indwelling Foley catheter. Initial POC does not include problem/goals interventions related to indwelling Foley. COS Patient #12- Patient readmitted 9/2/23. Initial SC assessment identifies patient to have anxiety fear of death and dying and feelings of meaningless, despair and hopelessness. The IDG POC did not include related problem, goals and interventions.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Admitted with indwelling Foley catheter. The initial catheter was 18fr. The nurse changed the catheter 4/22/24 and inserted 16 Fr. There were no orders specific to Foley upon initial chart review. Reportedly, the nurse inadvertently failed to write the order. A late and complete order was written during survey regarding Foley/ balloon sizes and monthly and prn catheter changes. COS.

Upon patient client record review, 3 of 14 (Patient #2, 3, 12) 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 #2: Patient admitted 4/19/24 with 18 Fr. Foley catheter in place. 04/22/24 SN Note states that Foley catheter done using Fr #16. Noted to have very cloudy urine and foul order. "done" is not clear documentation for inserting catheter and balloon size is not specified. Patient #3: Patient admitted 2/27/24 in Benefit Period #1 (2/27-5/26/24). However, there is a note, assigned to NP, identified as Face to Face 5/11/24 with no signature for NP and/or signature date. Patient #12: Patient admitted in 3rd benefit period (2/29-4/28/24). 3/18/24 F2F note, assigned to NP, has no signature or date of signature.