Every finding on record at Residential Healthcare of NE PA, LLC

Upon patient record review, 2 of 19 (Patient #9, 12) 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 #9 - SOC 01/24/24 - initial bereavement completed 02/08/24. Patient #12 - SOC 08/18/23 - initial bereavement completed 12/13/23.

Upon patient record review, 1 of 19 (Patient #8) 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 #8 - RN assessment completed on 12/21/23 next RN assessment completed on 01/06/24 - greater than 15 days.

Upon patient record review, 1 of 19 (Patient #15) 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 medications and treatments. Patient #15 - POC dated 02/01/24 - SN completed PT/INR 02/02/24 VO written on 02/02/24 - results of test and repeat 02/05/24, on 02/05/24 results and repeat on 02/12/24 and on 02/26/24 results and repeat in 1 week. Did not specify what test or if finger stick or peripheral.

Upon client record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10 - POC dated 01/13/24 order to change foley catheter using #22 - 30cc foley catheter but SN changed on 03/13/24 and inserted #20-30cc catheter. In addition, SN visit note on 03/15/24 foley catheter removed - no order for foley catheter removal.

Upon patient record review 2 of 19 (Patient #7, 11) 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 #7 - Aide visit frequency 2 x week, care plan tasks shampoo and change linen ordered weekly - aide provided shampoo and changed linen both visits week of 02/13/24. Aide provided linen change both visits week of 02/18/24 and week of 02/25/24. Patient #11 - Aide visit frequency 3 x week, care plan tasks shampoo hair 2 x week and change linen 1 x week - aide provided shampoo every visit and changed linen 2 x week - week of 12/10/23. SN added to care plan 12/28/23 use mechanical lift every visit for transfers - transferred without use of mechanical lift all visits week of 01/07/24 and 02/04/24.

Upon patient client record review, 2 of 19 (Patient #13, 15) 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 #13 - SN documented on visit note 02/07/24 "g-tube cleaned and dressed" did not document specific wound care that was ordered. Patient #15 - SN documented on visit note 02/12/24 "INR due today - 2.3" and on 02/26/24 "INR completed today - 1.5" did not document specific - finger stick or peripheral or patient tolerance to procedure.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #6 - POC dated 02/15/24 did not specify who was responsible for ostomy care hospice or facility nurse.

Upon personnel record review, 1 of 17 (Personnel #9) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #9 - Graduated with MSW in July 2023 - has not had 1 year of social work experience in a healthcare setting as a MSW. She has worked in multiple position in healthcare but not as a MSW.