Every finding on record at Seacliff Hospice Inc.

Upon patient record review, 1 of 7 (Patient #4) did not contain evidence of a comprehensive Medication Profile: Patient #4: The RN SOC assessment documented that the patient was on Oxygen 2-5 lpm. This was not included on the Medication Profile.

Upon patient record review, 2 of 7 (Patients #6 and 7) did not contain evidence that the Initial Comprehensive Assessment included a Bereavement Risk 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 Risk Assessment (BRA) is incorporated into the Plan of Care and is considered in the Bereavement Plan of Care: Patient #6: SOC 10/01/24. There was no initial Bereavement Risk Assessment located within the record. Patient #7: SOC 09/27/24. There was no initial Bereavement Risk Assessment located within the record.

Upon patient record review, 2 of 7 (Patients #2 and 4) did not contain evidence that the Hospice had 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: During Surveyor-attended home visit on 06/03/25, it was noted that the patient had a right leg BTK amputation. The patient was voicing his ongoing desire to receive assistance with his prosthesis and Physical Therapy services. The current IDG POC did not reflect that this patient had a right BTK amputation. The 'Mobility' section of the POC noted, "Assess for alteration in mobility and effect upon ADLs, and need for assistance. Potential fall risk." Patient #4: The RN SOC assessment documented, "Patient has orthopnea, requiring 3-4 pillows at night to enable adequate breathing and sleeping." This pertinent information was not included on the POC. The RN SOC also documented that patient was a DNR. However, this was not included on the physician-ordered POC.

Upon patient record review, 1 of 7 (Patient #2) did not contain evidence that the IDG, in collaboration with the Attending Physician, had reviewed, revised and documented an individualized Plan of Care, as frequently as the patient's condition requires but no less frequently then every 15 calendar days: Patient #2: SOC 05/11/2025. The clinical record contained IDG Meeting notes dated 05/11/25. However, there were no other subsequent IDG Meeting notes located beyond that date.

Upon patient record review, 7 of 7 (Patients #1, 2, 3, 4, 5, 6, and 7) did not contain evidence that each patient record contained: A signed Election of Hospice Benefit Statement in accordance with 418.24. The Election Statement must include the following information: • Identification of the particular hospice that will provide care to the individual; • The individual's or representative's (as applicable) acknowledgement that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment • The individual's or representative's (as applicable) acknowledgement that the individual understands that certain Medicare services are waived by the election • The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive • The signature of the individual or representative; and • Identification of the particular hospice and of the attending physician. The individual or representative must acknowledge the identified attending physician was his or her choice. Patients #1, 2, 3, 4, 5, 6 and 7: There were no signed Election of Hospice Benefit Statement(s) within these files. Each of their signed 'Consents' included a section wherein the patient/representative had entered their choice of Attending Physician if any.

Upon Inpatient contract review, 1 of 4 (San Marino Manor) did not contain evidence that the Hospice patient's Inpatient clinical record must include verbiage requiring that a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from the Inpatient Facility.

Upon personnel record review, 3 of 11 (Personnel #3, 4, and 5) did not contain evidence that the Hospice had obtained a Criminal Background Check on all contracted individuals who have direct patient care and access to patient records: Personnel #3, 4, and 5: There were no Criminal Background Checks located within these personnel files.