Every finding on record at Soul Hospice Care Inc

Upon patient record review, 9 of 14 (Patient #2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 2,3,4,5,6,7,8,9,10: On the RN comprehensive assessment the RN does not take into consideration the imminence of death. Corrected on site.

Upon patient record review, 4 of 14 (Patient #1,2,9,10) 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 1: On the medication profile there is an order for Pradaxa, the plan of care does not contain a risk for bleeding with goals and interventions. Corrected on site. Patient 2: On the medication profile there is an order for Aspirin daily the plan of care does not contain a risk for bleeding with goals and interventions. Corrected on Site Patient 9: On the medication profile there is an order for Aspirin the plan of care does not contain a risk for bleeding with goals and interventions. Corrected on Site. Patient 10: On the medication profile there is an order for Aspirin daily the plan of care does not contain a risk for bleeding with goals and interventions. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: There is evidence that the patient has a hospital bed in his home, there is not a hospital bed listed on the plan of care. Corrected on site.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 5: There is evidence in the patient record that the IDG met and documented a plan of care on 07/21/25, the next IDG was on 08/09/25, the IDG did not review, revise and individualize the plan of care less than every 15 days.

Upon client record review, 2 of 14 (Patient #4,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: On the plan of care there is an order for LVN once weekly and RN every 14 days. There are no LVN visits or RN visits the week of 8/17. Corrected on site. Patient 8: On the recent plan of care there is an order for LVN one time per week, on June 30 and July 2nd there were scheduled LVN visits made, there is no documentation of need of prn visit or an order for prn visits on the plan of care.

Upon patient record review, 2 of 14 (Patient #3,5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 3: On the aide plan of care there is an order for record bowel movements, feeding assistance, assist with oral medications as per RN instruction, encourage fluids as tolerated, change patient linens, this order does not contain a frequency. Corrected on Site Patient 5: On the aide plan of care there is an order for record bowel movements, feeding assistance, change patient linens, there is no order for frequency. Corrected on Site

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated. There was inconsistency with the designated box for SOC date on initial Plan of Care. The actual SOC date was 7-12-22. The designated box for SOC read 6-1-22 not 7-12-22.