Every finding on record at Sm Glory Hospice Inc

Upon patient record review 4 of 14 (Patient #1,7,9,10) 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 1: Patient admitted on 11/18/2024. Psychosocial assessment completed on 12/04/2024, 16 days after election. RN documented in the initial comprehensive assessment that the SW visit was needed as patient/facility was requesting help with advance directives. Patient 7: Patient admitted on 11/18/2024. Psychosocial assessment completed on 12/04/2024, 16 days after election. RN documented in the initial comprehensive assessment that the SW visit was needed. Patient 9: Patient admitted on 11/18/2024. Psychosocial assessment completed on 12/04/2024, 16 days after election. RN documented during the initial comprehensive assessment that the SW visit was needed as patient/facility was requesting help with advance directives. Patient 10: Patient admitted on 11/18/2024. Psychosocial assessment completed on 12/04/2024, 16 days after election. RN documented during the initial comprehensive assessment that the SW visit was needed as patient/facility was requesting help with advance directives.

Upon patient record review, 2 of 14 (Patient #8, 9) 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: No evidence that RN visits for the month of November were completed. All visit documentation for that month were blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver. Patient 9: No evidence that RN visits for the month of November were completed. All visit documentation for that month was left blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver.

Upon patient record review, 1 of 14 (Patient #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 10: The active medication list indicates that the patient takes Eliquis 5mg twice a day as a blood thinner. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care.

Upon patient record review, 3 of 14 (Patient #8,9,10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 8: No evidence of routine visit frequency for spiritual coordinator on plan of care. Plan of care order has visit frequency as 1 visit as needed per month. Corrected during survey. Patient 9: No evidence of routine visit frequency for spiritual coordinator on plan of care. Plan of care order has visit frequency as 1 visit as needed per month. Corrected during survey. Patient 10: No evidence of routine visit frequency for spiritual coordinator on plan of care. Plan of care order has visit frequency as 1 visit as needed per month. Corrected during survey.

Upon client record review, 2 of 14 (Patient #8, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: No evidence that RN visits for the month of November were completed. All visit documentation for that month were blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver. Patient 9: No evidence that RN visits for the month of November were completed. All visit documentation for that month were blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver.