Every finding on record at Vialife Hospice LLC

Upon patient record review 1 of 19 (Patient #3) 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 3:The family requested social worker visit upon admission date of 6/11/24, the social worker did not have any documented communication with family until 6/20/24, psychosocial assessment was not performed until 6/30/24.

Upon patient record review, 3 of 19 (Patients #5, #6, #7) 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 Patient 5: The medication profile from the facility has cyanocobalamin 100mcg daily however, this is not on hospice medication profile. Patient 6: The medication profile does not list lactulose po 2 table spoons prn, Dorzolaminde/timolol eye drops to both eyes which were found in the home, the profile does list scopolamine SL liquid and extra strength Tylenol, the caregiver was unaware of these medications. Patient 7: The medication profile does not have Zofran 4 mg under the tongue, but medication was found in the home.

Upon patient record review, 2 of 19 (Patients #3, #12) 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: There was no bereavement assessment documented. Patient 12: There was no bereavement assessment documented.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 9: There is no documented comprehensive visit between dates of 3/31/25 through 4/28/25.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 1: Dr RG is listed as the patient's choice for attending, there is no evidence that hospice has collaborated with the attending physician in developing plan of care.

Upon patient record review, 3 of 19 (Patients #2, #4, #10) 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 2: Patient is identified as a fall risk, there is no goals, plans or interventions identified to manage. Patient 4: The documentation identifies patient having peritoneal dialysis, there are no documented goals, plans, or interventions identified.-Corrected on site Patient 10: Upon admission, patient is identified as having a colostomy, there are no goals, plans or interventions to manage. corrected on site

Upon patient record review, 3 of 19 (Patients #5, #6, #7) 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 5: The medication order from the facility has cyanocobalamin 100mcg daily, the hospice has no order for. Patient 6: There are no medication orders for lactulose po 2 table spoons prn or Dorzolaminde/timolol eye drops to both eyes which were medications found in the home. Patient 7: There is no medication order for Zofran 4 mg under the tongue but medication was found in the home.

Upon patient record review, 4 of 19 (Patients #2, #8, #12, #14) 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 2: It is documented in the admission note that patient has oxygen concentrator, walker, cane, nebulizer and wheel chair, but there is no order for the medical equipment.-corrected on site. Patient 8: Upon admission, nurse notes that patient has gait belt, but there is no order for it.-corrected on site Patient 12: On recertification visit on 4/29/25, nurse identifies that a gait belt is in use for transfer, there are no orders for gait belt.-corrected on site Patient 14: Patient has albuterol nebulized medication on order, but does not have order for a nebulizer-corrected on site

Upon client record review, 1 of 19 (Patients #1) 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: Dr RG is listed as the patient's choice for attending, there is no evidence that hospice has updated attending physician since admission.

Upon patient record review, 2 of 19 (Patients #5, #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient 5: Nurse identified patient as a 2 person max assist on recert visit, the aide care plan does not identify this need. Patient 8: Nurse identified patient as being 1 person assist with gait belt for all transfers, there is no aide care plan identifying requirement.-corrected on site

Upon patient client record review, 2 of 19 (Patient #1, #4) 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 identified problems of Pain and Sleep do not have complete documentation in the goal section. For pain the goal has "patient will report level of pain using ______ scale" and for sleep the goal has "............increased energy as evidenced by ________ within ______". Patient 4: The plan of care has incomplete documentation under the Skin plan of care order on 4/7/25 the goal has multiple blanks in it. "Evidenced by _______ within _____"

Upon client record review, 1 of 1 applicable (Patient #6) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient # 6. The clinical record dated 6/30/21 indicated the patient was transferring to another hospice and that patient is discharged effective 6/29/21. The record did not have evidence that a discharge summary and a copy of the patient's plan of care, medication profile, clinical notes, Face to face dated 6/20/21 and Certificate of Terminal Illness were sent to the receiving hospice at the time the patient was transferred.