Every finding on record at Sunny Hospice Care, Inc.

Upon patient record review, 1 of 14 (Patient #4) 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 #4, Patient has no care plan for pain. Initial RN assessment states patient is uncomfortable because of pain.

Upon patient record review, 7 of 14 (Patient #1,2,6,10,11,13,14) 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, No DME on POC, patient has walker and wheelchair. Patient #2, No DME on POC, patient has walker. Patient #6, Patient has his own hospital bed, missing under DME on the POC. Patient #10, Patient needs O2 concentrator and E tank, no on POC. Patient #11, Patient has walker, missing under DME on POC. Patient #13, Patient needs air mattress, hospital bed, suction machine, E tank, missing under DME on POC. Patient #14, Patient needs air mattress, hospital bed and commode, missing under DME on POC.

Upon client record review, 2 of 14 (Patient #7, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7, MSW frequency order 1x/month. Patient seen 10/18/23, no visit month of November or December. Patient #12, MSW declined, no frequency orders. Visits made on 7/12/23, 8/9/23, 9/13/23.

Upon patient client record review, 3 of 14 (Patient #4,6,8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #4,6,8, Missing start of care date on consents.