Every finding on record at Saint Daniel Palliative Care Inc

Upon patient record review 1 of 16 (Patient #13) 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 13: The record indicates that the spiritual assessment was completed on 01/26/2023, 6 days after election of hospice benefits.

Upon patient record review, 1 of 16 (Patient #13) 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 13: No evidence that an initial bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 01/20/2023, assessment completed 6 days after on 01/26/2023.

Upon patient record review, 3 of 16 (Patient #7,11,14) 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 7: Patient has Divalproex 500mg and Depakote 500mg both daily for seizures on the medication profile. There was no evidence of problems, goals, and interventions related to seizures included in the plan of care. Patient 11: Patient has Oxcarbazepine 150mg daily for seizures on the medication profile. There was no evidence of problems, goals, and interventions related to seizures included in the plan of care. Patient 14: Patient has Oxcarbazepine 600mg daily for seizures on the medication profile. There was no evidence of problems, goals, and interventions related to seizures included in the plan of care.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: Plan of care indicates Chaplain's routine frequency as once weekly. The record indicated that the patient received one visit on 10/01. No evidence that weekly routine visits were completed after the 10/01/2022 visit. No evidence that a missed visit note or evidence that an order was obtained to change the frequency to once monthly.

Upon patient record review 1 of 14 (Patient #14) 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 14: Plan of care indicates aide routine frequency was twice weekly. The record did not indicate that the patient received a visit from the aide while on services. No evidence that missed visit notes or evidence that an order was obtained to change the frequency or discontinue aide visits.