Every finding on record at Trustable Hospice, Inc

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7,9,10, no evidence of initial bereavement completed.

Upon client record review, 3 of 14 (Patient #9,10,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9, No evidence of telephone order for SC visit. Telephone visit completed on 1/12/24. Patient #10, No evidence of telephone order for MSW and SC. Telephone visit completed on 4/28/24 for MSW. Telephone visit completed on 4/29/24 for SC. SC frequency was 1x/month, no evidence of May visit completed for SC. Patient #13, No evidence of telephone order for SC. Telephone visit completed on 8/15/23.

Upon patient record review 3 of 14 (Patient #1,7,8) 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, Care plan directs feeding assistance. No evidence on 5/6/24 and 5/27/24 task was completed, box was left empty. Patient #7, Care plan directs dress in street clothes. No evidence on 5/31/24 task was completed, box was left empty. Patient #8, Care plan directs one person transfer. No evidence on 4/29/24 task was completed, box was left empty.

Upon patient record review 3 of 14 (Patient #8,9,13) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8, RN supervisory visit 4/6/24 then 5/4/24. RN visit on 4/20/24 was decline and supervisory visit was not completed. Patient #9, RN supervisory visit on 4/3/24 then 5/1/24. RN visit on 4/17/24 was decline and supervisory visit was not completed. Patient#13, RN supervisory visit on 4/7/24 then 5/5/24. RN visit on 4/21/24 was decline and supervisory visit was not completed.

Upon patient client record review, 3 of 14 (Patient #2,9,11) 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 #2, No evidence of MSW signature on IDG note dated 5.12.24. Patient #9, No evidence of complete SC note on 1.12.24 including missing signature. Patient #11, No evidence of MD or SC signature on IDG note dated 6.9.24