Every finding on record at Trilogy Hospice Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#1,#2,#3: Patient primary language was not English. There was no evidence that Patient rights and responsibilities we provided in a written language the patient understands. Corrected on site.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#4: There is no evidence of an initial spiritual assessment completed for patient.

Upon patient record review, 1 of 4 (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. Patient#4: There is no evidence of an initial bereavement assessment being completed for patient.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#9: There is no evidence RN included wound measurements in comprehensive assessment between 5/2/25-5/30/25.

Upon patient record review, 2 of 14 (Patient #3, #4) 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#3: There is no evidence of documentation of patient needs or progress of goals by MSW for IDG 2/28, 3/24, 3/28, and 4/11. MSW only states that she will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family. Patient#4: There is no evidence of documentation of patient needs or progress of goals by MSW for IDG 4/11, 4/25, 5/9, 5/23. MSW only states that she will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family.

Upon patient record review, 2 of 14 (Patient #7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#7: The record indicates the plan of care contains an intervention stating the SN to perform diabetic foot exam and care upon every visit. There is no evidence or documentation this was completed or performed on SN visits 5/23, 5/21, 5/16 and 5/9. Plan of care corrected on site. Patient#8: The record indicates the plan of care contains an intervention stating the SN to perform diabetic foot exam and care upon every visit. There is no evidence or documentation this was completed or performed on SN visits 5/29, 5/24, 5/22. Plan of care corrected on site.

Upon patient record review 2 of 14 (Patient #2, #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#2: The record indicates an order was placed on 4/9/25 for podiatry. There is no evidence of follow- up on this order documented. Patient#3: The record indicates an order was placed on 2/27/25 for podiatry. There is no evidence of follow- up on this order documented.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#9: There is no evidence on any IDG meeting of documented collaboration of care and communication with the wound care company providing debridement care of the stage IV sacral wound.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient#3: The record indicates there is a physician narrative for recertification starting 5/6/25. However, there is no evidence of physician signature on recertification for 5/6/25-8/13/25.

Upon patient record review, 1 of 14 (Patient #8) 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. Patient#8: The record indicates patient signed form for full code. However, the electronic medical record shows patient is DNR. Corrected on site.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 5: The medication profile contains Duoneb 0.5/3mg/3ml 1 vial every 6 hours prn. The concentration does not indicate the proper dose amount for the 0.5 (mg,ml) part of the concentration.

Upon patient record review, 1 of 5 (Patient #5) 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 medications and treatments. Patient 5: Patient 5: The Plan of care contains Duoneb 0.5/3mg/3ml 1 vial every 6 hours prn. The concentration does not indicate the proper dose amount for the 0.5 (mg,ml) part of the concentration.

Upon patient client record review, 2 of 5 (Patient #3,#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. Patient 3: The medical record contains a narrative note by the RN on 4-9-22 stating Supervisory visit performed. There is no evidence of documentation of a supervisory visit being completed in that section as far as naming the discipline being supervised or any notes regarding the actual supervision. The RN did do timely supervisory visits on 3-26-22 and 4-23-22. Patient 5: The medical record contains a narrative note in an IDG completed on 3-18-22 that states Pt being seen by CHHA 2 times per week. There was no order for an aide, the aide did not see the patient.