Every finding on record at Superior Hospice Inc

Upon patient record review 3 of 14 (Patient #8, 9, 11) 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. (Per agency policy each discipline will complete their section of the comprehensive assessment within 5 days). Patient #8 - SOC 06/15/2023 - Spiritual assessment completed visit on 06/23/2023. Patient #9 - SOC 07/25/2023 - Spiritual completed visit on 08/09/2023. Patient #11 - SOC 05/29/2023 - Spiritual completed visit on 06/12/2023.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #10 - Comprehensive assessment did not have of documentation of imminence of death.

Upon patient record review, 4 of 14 (Patient #5, 6, 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 #5 - POC dated 06/12/2023 visit frequency for MSW and SC PRN. Patient #6 - POC dated 07/21/2023 visit frequency for MSW PRN. Patient #9 - POC dated 08/01/2023 visit frequency for MSW and SC 1 visit then PRN. Patient #10 - POC dated 07/25/2023 visit frequency for MSW and SC 1 visit then PRN.

Upon patient record review, 3 of 14 (Patient #11, 12, 13) 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 #11 - POC dated 05/29/2023 did not contain DME or supplies but patient getting briefs and has walker and w/c. (Corrected on site) Patient #12 - POC dated 06/29/2023 did not contain DME or supplies but patient getting briefs and has walker and w/c. (Corrected on site) Patient #13 - POC dated 06/26/2023 did not contain DME or supplies but patient getting briefs and has walker and w/c. (Corrected on site)

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #12 - New order for wound care written on 07/20/2023 but POC not revised with new problem "altered skin integrity". (Corrected on site)