Every finding on record at Th Caring Hospice Care Inc

Upon patient record review, 1 of 16 (Patient #1) 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 1: No evidence that a bereavement risk assessment was completed at the time that the chart was surveyed.

Upon patient record review, 1 of 16 (Patient #1) 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: The medical record indicated that the patient uses oxygen at 3L via NC continuously. No evidence of problems, goals and interventions related to oxygen safety on the plan of care.

Upon patient record review, 1 of 16 (Patient #4) 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 4: The plan of care has orders for aide services to start on 04/27/2025. No evidence that the RN entered the written aide plan of care until 05/12/2025. The written aide plan of care did not contain any tasks to be completed by the aide.

Upon patient record review 2 of 16 (Patient 1,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Aide plan of care has orders for the aide to take the patients vital signs (blood pressure, heart rate, temperature, and a respirations) at every visit. No evidence that vital signs were obtained on the visits that occurred on 03/26/2026 and 04/02/2026. Patient 4: The medical record indicated that the aide completed one visit for each of the following weeks: 04/27/2025, 05/4/2025, 05/11/2025, and 05/18/2025 where she provided personal care (showers) without a written plan of care.

Upon patient record review, 1 of 5 (Patient #4) 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. This patient did not have an initial bereavement risk assessment.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. The first IDG meeting was held on 11-12-22. The patient had order for IDG every 14 days on POC. The patient passed away on 11-27-22. There have been no IDT meetings since SOC.

Upon patient client record review, 1 of 5 (Patient #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. This patient's discharge summary had conflicting information. The reason for discharge selected in drop down was "Revocation". In the body of the note, the visit note indicated patient had passed away.