Every finding on record at Psl Hospice Care, Inc

Upon patient record review 3 of 14 (Patient #7,10,11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7,10, SC initial assessment was not completed as SC was unable to reach family by phone. No evidence of SC initial assessment completed on RN initial assessment. Patient #11, No evidence of RN assessment completed for spiritual or psych social. Patient declined both MSW and SC services.

Upon patient record review, 1 of 14 (Patient #11) 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 #11, Patient declined SC and MSW. No evidence of bereavement risk assessment completed.

Upon patient record review, X of X (Patient #) 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 #6, RN frequency every 2 weeks and LVN 1x/week, RN visits completed 3/29, 4/26. No evidence of RN visit every 15 days. Patient #7, SN frequency 1x/week, RN visits completed 2/28, 3/13, 5/29. No evidence of RN visits every 15 days.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 #1,2,5,6,7,8,9,10, No evidence of initial care plan for funeral planning. Initial psych social does not identify funeral home. Patient #3,4, No evidence of initial care plan for funeral planning or full code status. Initial psych social does not identify funeral home. Initial assessment documents patient full code status.

Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,12,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW visit on 4/8, 5/6, 6/4, 7/3 all completed as telephone visits with no evidence of order for telephone visit. SC visit on 4/8, completed as telephone visits with no evidence of order for telephone visit. Patient #2, MSW visit on 2/6 and 5/3 completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/2 completed as telephone visits with no evidence of order for telephone visit. Patient #3, MSW visit on 7/15 and SC visit on 7/15, completed as telephone visits with no evidence of order for telephone visit. Patient #4, MSW visit on 5/12, 6/4, 7/3, completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/10, completed as telephone visits with no evidence of order for telephone visit. Patient #5, MSW visit on 6/1, completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/30, completed as telephone visits with no evidence of order for telephone visit. Patient #6, MSW visit on 3/30 and 7/4, completed as telephone visits with no evidence of order for telephone visit. SC visit on 4/3 and 6/24, completed as telephone visits with no evidence of order for telephone visit. RN frequency every 2 weeks and LVN 1x/week, RN visits only completed 3/29, 4/26. Patient #7, SN frequency 1x/week. No evidence of visit completed the week of 4/24. 4/29 or 5/6. MSW visit on 3/1, 4/3, 5/3, completed as telephone visits with no evidence of order for telephone visit. SC visit on 3/3 and 5/21, completed as telephone visits with no evidence of order for telephone visit. Patient #8, MSW visit on 5/30, completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/31, completed as telephone visits with no evidence of order for telephone visit. MSW frequency 1x/month, no evidence of MSW visit completed in June. Patient #9, MSW visit on 4/29, 5/23, 6/7, 7/23, completed as telephone visits with no evidence of order for telephone visit. SC visit on 4/29 completed as telephone visits with no evidence of order for telephone visit. Patient #10, MSW visit on 2/28, 3/6, 4/12, completed as telephone visits with no evidence of order for telephone visit. MSW frequency 1x/month, no evidence of MSW visit completed in May. Patient #12, MSW visit on 5/5, completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/6, completed as telephone visits with no evidence of order for telephone visit. Patient #13, MSW visit on 6/25, completed as telephone visits with no evidence of order for telephone visit. SC visit on 6/24, completed as telephone visits with no evidence of order for telephone visit. Patient #14, MSW visit on 5/18, completed as telephone visits with no evidence of order for telephone visit. SC visit on 5/17, completed as telephone visits with no evidence of order for telephone visit.

Upon patient record review 1 of 14 (Patient #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #13, Aide care plan documents street clothes, pj/gown, diet, fall precaution, bleeding precaution. Aide did not complete these tasks. Aide documented tidy room and bowel movement as tasks completed. No direction on care plan to complete.