Every finding on record at Trust Care Hospice, Inc

Upon patient record review, 3 of 14 (Patient #3,6,8) 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 #3 - The initial risk assessment completed on 03/18/26 documented that the bereaved was listed as low risk with only one risk factor "exhaustion" listed. This risk assessment did not include the name of the primary bereaved. Patient #6 - The initial risk assessment completed on 02/25/26 documented that the bereaved was listed as low risk with only one risk factor "exhaustion" listed. This risk assessment did not include the name of the primary bereaved. Patient #8 - The initial risk assessment completed on 02/07/26 documented that the bereaved was listed as low risk with only one risk factor "exhaustion" listed. This risk assessment did not include the name of the primary bereaved.

Upon patient record review, 3 of 14 (Patient #1,6,8) 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 patient's POLST form showed patient chose to be a full code. There was no evidence of problems, goals, or interventions related to that full code status. Patient #6 - The patient's medication profile showed patient was taking Eliquis as a blood thinner daily. There was no evidence of problems, goals, or interventions related to the bleeding risk. Patient #8 - The patient's POLST form showed patient chose to be a full code. There was no evidence of problems, goals, or interventions related to that full code status.

Upon patient record review, 1 of 14 (Patient #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 #3 - The medication profile listed the medication albuterol 0.083% nebulized every 4 hrs prn. There was no evidence that a nebulizer machine was added to the DME list on the plan of care.

Upon client record review, 8 of 14 (Patient #1, 3, 4, 5, 6, 7, 8,10) 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 #1 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #3 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #6 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #8 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the spiritual care coordinator. Patient #10 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patients 1,3,4,5,6,7,8 showed an IDG was held on 05/02/26, however did not include all discipline signatures as required by the agency process or proof of attendance at the IDG.

Upon patient record review 2 of 14 (Patient #2,6) 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 #2 - The aide plan of care dated 09/08/25 had a frequency order for aide visits one time per week. The week of 04/26/26 - 05/02/26 had documented visits completed on 04/26/26 and 04/30/26 without evidence of an order for an extra visit. Patient #6 - The aide plan of care dated 02/25/26 had a frequency order for aide visits two times per week. The weeks of 04/05/26, 04/12/26, and 04/19/26 had evidence that only one aide visit was completed in each week: 04/07/26; 04/14/26; and 04/21/26. The medical record showed no evidence of a change in frequency or missed visit documentation.

Upon patient record review, 3 of 5 (Patient #1, #2, #3) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1-#3: There was no evidence that the comprehensive assessment takes into consideration imminence of death. COS

Upon patient record review, 2 of 5 (Patient #1 and #3) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medication profile included acetaminophen 650 mg rectal suppository, take one every 6 hours PRN and acetaminophen 500 mg every 6 hours PRN however, there was no maximum allowable dose. COS Patient #3: The medication profile included acetaminophen 650 mg rectal suppository, take one every 6 hours PRN and Tylenol 500 mg 2 tablets daily however, there was no maximum allowable dose. In addition, listed diclofenac sodium 1% topically without evidence of specific areas for application. COS

Upon patient record review, 2 of 5 (Patient #1 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 medications and treatments. Patient #1: The orders included acetaminophen 650 mg rectal suppository, take one every 6 hours PRN and acetaminophen 500 mg every 6 hours PRN however, there was no maximum allowable dose. COS Patient #3: The orders included acetaminophen 650 mg rectal suppository, take one every 6 hours PRN and Tylenol 500 mg 2 tablets daily however, there was no maximum allowable dose. In addition, listed diclofenac sodium 1% topically without evidence of specific areas for application. Upon home visit, the patient had an E tank in the home and when LVN asked if he used for he stated used when short of breath (LVN translated to this surveyor) however, there was no evidence of an order for the Oxygen usage. COS

Upon patient record review, 1 of 5 (Patient #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 3 Upon home visit, the patient had an E tank in the home and when LVN asked if he used for he stated used when short of breath (LVN translated to this surveyor) however, there was no evidence of an order for the Oxygen DME.

Upon patient record review, 3 of 5 (Patient #1, #2, #3) 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 Patients #1-#3: The record did not contain evidence of hospice medical director or designee certification of terminal illness. The completed certification was completed by attending. COS

Upon patient client record review, 2 of 5 (Patient #4 and #5) did not evidence that each patient record contains physician orders. Patients #4 and #5: There was no evidence of order for discharge for medical stabilization.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, #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 #1: The nurse admission noted patient was admitted on respite as well as IDG notes on 04/27, 05/11, and 05/25 however, initial plan of care indicated patient was admitted on routine care. COS Patient #2: The nurse admission noted patient was admitted on respite as well as IDG notes on 04/30, 05/14, and 05/28 however, initial plan of care indicated patient was admitted on routine care. COS Patient #3: The nurse admission noted patient was admitted on respite as well as IDG notes on 04/271, 05/15, and 05/19 however, initial plan of care indicated patient was admitted on routine care. COS Patient #4: The discharge plan of care and summary noted patient was discharged due to extended prognosis and stabilization, however the chart included revocation documented 03/31/2023. Agency confirmed patient was discharged due to stabilization. Patient #5: The discharge plan of care and summary noted patient was discharged due to extended prognosis and stabilization, however the chart included revocation documented 04/01/2023. Agency confirmed patient was discharged due to stabilization.

Upon client record review, 2 of 5 (Patient #4 and #5) did not have evidence that the discharge summary includes all required information. Patient #4: The discharge summary contained a section to indicate if current plan of care was included however, this was not marked and there was no evidence this was include with discharge summary. Patient #5: The discharge summary contained a section to indicate if current plan of care was included however, this was not marked and there was no evidence this was include with discharge summary.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. COS