Every finding on record at Upwm Healthcare LLC

Upon patient record review 1 of 5 (Patient #1) 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 #1, Patient declined spiritual care services. No evidence of comprehensive spiritual assessment completed by any discipline.

Upon patient record review, 1 of 5 (Patient #1) 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: During home visit, LVN asked patient if she has pain and how she rates her pain. Patient rates pain at 8/10, stating she doesn't want to become addicted to pain medication. The LVN explains the use of Norco and when she should notify agency that the medication is not effective anymore. Patient states she only take a half tablet at a time. Current order for Norco5/325mg, one tablet every 4 hours as needed for severe pain. Not to exceed 3gm of acetaminophen from all sources. Patient verbalized she is not following the order for Norco which was ordered on 8/15/25 the date of her admission.

Upon patient record review, 3 of 5 (Patient #1,4,5) 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 #1,4,5, No evidence of bereavement assessment completed.

Upon patient record review, 1 of 5 (Patient #4) 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 #4, MSW initial assessment does not identify funeral home. No evidence of goals and intervention

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, RN frequency every 14 days, RN visit completed 8/26/25 and 9/2/25. No evidence of these visits occurring every 2 weeks.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Upon 1 of 1 home visit, LVN was not observed washing hands prior to entering nursing bag multiple times to remove equipment to take patient vital signs.

Upon patient client record review, 2 of 5 (Patient #4,5) did not have evidence that each patient record contains Advance Directives. Patient #4, No evidence of POA was uploaded to chart. Documentation on the consent documents patients has a POA. Consent does not document if copy was received or not. Patient #5, No evidence of POA was uploaded to chart. Documentation on the consent documents patients has a POA. Consent states copy obtained.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Agency does not have prior patient records therefore, no evidence confidentiality has been maintained.

Upon review of unduplicated census, the patient charts from the initial survey were not available for review as the agency was unable to locate records.