Every finding on record at Trinitas Hospice Care LLC

Upon patient record review, 4 of 5 (Patients #1, 2, 3, 4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1, #2, #3, #4: Did not have attending physician choice box checked on EOB form.

Upon patient record review, 5 of 5 (Patients #1, #2, #3, #4 and #5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 3 of 5 (Patients #1, #2 and #3) 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. Patients #1, #2 and #3: The Bereavement Coordinator made visit timely. However, the visit form was incomplete and did not have Bereavement risk score. During this survey a late entry was made to include score. Corrected On Site.

Upon patient record review, 3 of 5 (Patients #1, #2 and #3) 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: This patient had a wheel chair, BSC and oxygen. These items were not included on the Plan of Care. Patient #2: This patient had a wheel chair, walker, BSC, SC and oxygen. These items were not included on the Plan of Care. Patient #3: This patient had a wheel chair and SC. These items were not included on the Plan of Care. Corrected on site.

Upon patient record review 1 of 5 (Patient #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 Patient #4: HHA visit frequency was ordered on 7-9-22 for 2 x's week. During first benefit week there were no visits made by the aide. Visit frequency was not met. Corrected on site.

Upon patient record review, 2 of 5 (Patients #4 and #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4: The CTI for Benefit Period 1 duration has incorrect time period. The SOC was 7-9-22. The agency had benefit period listed as 7-9-22 to 11-6-22. The correct dates should have read 7-9-22 to 10-6-22 (90 days). Patient #5: The CTI for Benefit Period 1 duration has incorrect time period. The SOC was 9-20-22. The agency had benefit period listed as 9-20-22 to 12-22-22. The correct dates should have read 9-20-22 to 12-18-22 (90 days).

Upon patient client record review, 5 of 5 (Patients #1, #2, #3, #4 and #5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1 #2 and #3: Did not have attending physician choice box checked on EOB form. Patient #4: Did not have attending physician choice box checked on EOB form or SOC "effective date" filled in space provided. Patient #5: Did not have SOC "effective date" filled in space provided.

Upon patient client record review, 2 of 5 (Patients #4 and #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 #4: There were inconsistent CTI dates listed on Revocation form (8-13-22 to 11-10-20) and DC summary (7-9-22 to 11-060-22). These dates do not align with Benefit Period 1 dates that should read: 7-9-22 to 10-6-22. Patient #5: There were inconsistent CTI dates listed on Revocation form (8-13-22 to 11-10-20). The CTI dates should have read 9-20-22 to 12-18-22. Corrected on site.