Every finding on record at True North Healthcare LLC

Upon patient record review 1 of 14 (Patient #9) 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. Patient #9 admitted 06/27/23 SCP assessment completed on 7/03/23 (day 6).

Upon patient record review 2 of 14 (Patient #13,14) 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 #13 admitted 01/12/24 and discharged 06/26/24 due to transfer to another hospice. SC order on admission for 1visit monthly, no evidence of SCP assessment or visit. Patient #14 admitted 02/20/24 and discharged 03/05/24 due to hospitalization, SW ordered on admission, no evidence of a SW assessment or visit.

Upon patient record review, 2 of 14 (Patient #11,14) 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 #11,14 did not have evidence of a Bereavement Risk Assessment.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13 admitted 01/12/24 with order for SC once monthly. There was no evidence of an initial SC Comprehensive assessment, nor was there any documentation of SC visits or contact during the patients length of stay. The SC visit frequency remained on the Plan of Care during the entire stay. Patient was discharged on 06/26/24 per family request to transfer to another hospice.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients 11&12 did not have a Bereavement plan of care. There was documentation of one post death contact via phone and mailings sent per agency policy.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: •Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires. Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of their ability Patient #13 admitted 01/12/24 RN screened for SC needs, offered SC which was accepted by patient and family. Frequency order for SC once monthly. There was no evidence of an initial SC Comprehensive assessment, nor was there any documentation of SC visits or contact during the patients length of stay. The SC visit frequency remained on the Plan of Care during the entire stay. Patient was discharged on 06/26/24 per family request to transfer to another hospice.

Upon patient record review, 1 of 6 (Patient #1) did not have evidence in the patient record that the comprehensive assessment included a bereavement component completed within 5 days of the election of hospice. Patient 1: Patient admitted 7/20/21. Bereavement Assessment conducted on 7/30/2021.

Upon client record review, 1 of 6 (Patient #6) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient 6: Physician orders for 1 x week Nursing Services. There was no indication that Nursing visits were conducted during the weeks of 9/19/2021 and 9/26/2021.

Upon patient record review 1 of 4 applicable (Patient #1,) did not have evidence documentation in the patient record that a hospice aide provides services that were ordered by the IDG and included in the plan of care. Patient #1- Visit frequencies were ordered at 2x week. There were no Aide visits conducted during the week of 10/17/2021. On 9/18/2021, the Aide documented the application of barrier cream to the Patient. The RN had not ordered that specific task.

Upon patient record review 3 of 4 applicable (Patients #1, #3, #6) did not have evidence in the patient record that the hospice aides report changes in the patient's condition. Patient #1: Aide visit conducted on 9/18/2021, the Aide documented "redness to her tail bone. no broken skin, however, it is red. I applied barrier cream." There was no documentation that the Aide notified the RN of the change. Patient #3: Aide visit conducted on 9/15/2021, the Aide documented "Patient complained of pain on L (Left) knee. Was emotional for no reason." There was no documentation that the Aide notified the RN of the change. On 9/19/2021, the Aide documented "Observed boil/bump on outer R (Right) calf. Is beginning to become smaller in size. Patient denied any pain. Doesn't remember what happened. I have monitored the size and condition weekly during showers. No drainage or foul smell noted." There was no documentation that the Aide notified the RN. Patient #6: Patient #6 - On 9/18/2021 and 9/25/2021, the Aide documented the Patient ..."needs briefs". On 9/26/2021, the Aide documented ..."daughter came for visit on Saturday and delivered briefs for her." On 10/3/2021, the Aide documented ..."supplies were delivered, but only small quantity. Not enough for two weeks. Need gloves, pull ups and pads." Missing evidence in the documentation that the aide notified the RN of the needed supplies.