Every finding on record at Solace Hospice & Palliative Care, Inc.

Observed in Record Review. In 12 of 12 patient records reviewed, Surveyor observed that the documented goals on all records had not been measurable a few examples that were repeated on many charts are : Patient will maintain optimal mobility while under care. Fall Prevention will be maintained during care.Patient/Caregiver will receive optimal teaching and support as pulmonary functions change during care.Patient's anxiety will be controlled to a manageable level within period of time Patient will achieve optimal sleep/rest during care patient’s pain level will be well controlled with proper pain management regime, Promote optimal nutrition/hydration during care, Patient's pain will remain at comfortable level during care. patient will receive optimal level of pain or symptom management on short-term basis. respiratory goal : patient will remain comfortable in her declineskin Integrity will be maintained during care This issue was discussed and confirmed with organization leadership. .

Observed in Record Review. In 12 of 12 patient records reviewed, The surveyor observed on the POC that the frequency had not been included for over 3 months. The organization stated this was a EMR issue and that they wrote the frequency down on paper and communicated to staff, however the surveyor found no evidence of an order related to frequency only a written communication document. This issue was discussed and confirmed with organization leadership.

Observed in Data Session. the surveyor observed that no data collection of hand hygiene had been collected or analyzed to evaluate hand hygiene compliance in 2024 or 2025. The surveyor observed at the time of survey the organization had no analyzed data for hand hygiene. This issue was discussed and confirmed with organization leadership.

Observed in Individual Tracer. Hospice Medical Director providing clinical direction did not have clinical competencies on file for 2023,2024 or 2025. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, of live discharge to another Medicare facility the surveyor observed that the Hospice had not provided a summary of care to receiving facility when patient was transferred or at any point to date. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, of live discharges, the surveyor observed that no discharge summary was completed that included treatments, symptoms and pain management. The issue was discussed and confirmed with organization leadership.

Observed in Patient Home. During tracer activity in home visit #2 the surveyor observed two standing oxygen tanks that were unsecured. The staff member at one point had hit the cylinder with patient wheelchair almost knocking it over, but at no time during visit did the staff member educate on the standing oxygen tanks. The issue was discussed and confirmed with organization leaders.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization did not inform the patient verbally or in writing of the covered and non-covered items/services. In HV#3/RR#3, RR#6, and RR#9, the surveyor observed that no documentation found informing patient of their right to be notified of non-covered items. This was confirmed by the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to assess and reassess the patient and the patient's condition according to the defined time frames. In HV#1/RR#, HV#2/RR#2, RR#7, the Chaplain and Social Worker failed to complete their initial assessment within 5 days after the election of hospice. In RR#4, the Social Worker failed to complete their initial assessment and there was no documentation on file that Social Worker was refused. In RR#6, family refused due to COVID, yet there was no follow up. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, no evidence that the plan of care reflected the patient's assessed needs. Upon record review, it was noted that new problems were not being captured in the plan of care. Progress toward goals was captured in the IDG summary; however, new problems were not being addressed in the plan of care. For example in RR#5, patient was c/o nausea yet the plan of care did not include goals or interventions to address this identified need. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to provide aide services as per the plan of care. In HV#1/RR#1, the surveyor observed that there was a gap in service during BP #1 Weeks 5 and 6 patient received 1 aide visit per week, instead of 2. During Week 11-14, patient did not receive any aide visits. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, Medical Director did not review clinical information or sign the initial certificate of terminal illness. In RR#8, the surveyor noted that there was no signed CTI on file. This was confirmed by the DPCS.