Every finding on record at Solace Healthcare, Inc.

Upon patient record review 2 of 14 (Patient #2,8) 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 2: The record indicates that the psychosocial nor the spiritual assessment was completed within 5 calendar days following the election of hospice. Patient was admitted on 02/09/2024. Psychosocial assessment completed on 02/15/2024, 6 days after election. Spiritual assessment completed on 02/16/2024, 7 days after election. Patient 8: The record indicates that the psychosocial was not completed within 5 calendar days following the election of hospice. Patient admitted on 05/15/2024. Psychosocial assessment completed on 5/29/2024, 10 days after election.

Upon patient record review, 1 of 14 (Patient #2) 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 2: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 02/09/2024, assessment completed on 02/16/2024.

Upon patient record review, 3 of 14 (Patient #2,4,5) 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 2: Patient has current dx of Dysphagia. Patient also has chronic UTI's and currently has ESBL in the urine. There was no evidence of problems, goals, and interventions related to dysphagia or infections included in the plan of care. Corrected on site. Patient 4: Patient current takes Keppra 250mg daily for seizures, Plavix 75mg as a blood thinner, and Prozac 20mg as an anti-depressant. There was no evidence of problems, goals, and interventions related to seizures, risk for bleeding, or depression included in the plan of care. Corrected on site. Patient 5: Patient has a G-tube and has history of difficulty swallowing following anoxic brain injury. No evidence of problems, goals, and interventions related to risk for aspiration includes in the plan of care.

Upon client record review, 3 of 14 (Patient #1,6,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The record indicates that volunteer services were declined at the time of admit. The record shows that a volunteer made a visit on 07/02/2024. No evidence that an order was obtained to start volunteer services or that the visit was made at the request of the patient/caregiver. Patient 6: Plan of care indicates SN frequency as twice a week. The record did not indicate that the patient received 2 visits during the week of 05/19/2024. Only one visit documented for that week occurred on 5/23/2024. No missed visit note or evidence that an order was obtained to miss visit at the time that chart was reviewed. Patient 7: Plan of care indicates volunteer frequency as 3 times a month. The record indicates that the patient received 6 visits from the volunteer for the month of June. No evidence that an order was obtained to increase volunteer services.

Upon patient record review 3 of 14 (Patient #2,3,5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 02/18/24-03/05/24 (16 days), 03/05/24-03/20/24 (15 days), 04/01/24-04/16/24 (15 days), 04/16/24-05/01/24 (15 days), 05/01/24-05/20/2024 (19 days). Patient 3: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 04/16/24-05/01/24 (15 days), 05/01/24-05/17/24 (16 days), 05/28/24-06/15/24 (18 days). Patient 5: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 04/16/24-05/01/24 (15 days), 05/28/24-06/15/24 (18 days).