Every finding on record at Well Care Hospice Inc.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2: No evidence that SCC contributed to the IDG. SCC signed the IDG as completed but the area for contribution left blank.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Order written on 10/27/2024 has SN/LVN frequency ordered as every 14 days. No evidence that the SN is visiting the patient every 14 days. No evidence that a SN visit has been completed since 11/04/2024. No evidence that the visits were missed at the request of the patient/family or that an order was received by the physician to stop/decrease visit frequency.

Upon patient record review 7 of 14 (Patient #4,5,6,7,8,9,10) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #4,5,6,7,8,9,10 All had documentation of initial comprehensive nursing assessments. Agency staff interview indicates these patients were all hospital referrals, seen in the hospital with plan for discharging home and initial comprehensive assessments performed in hospital. Agency states all passed prior to going home from the hospital. There was no evidence the initial comprehensive assessment took place in the location where hospice services are being delivered or were intended to be delivered.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #1 IDG documentation dated 10/16/24 (for Recert 10/25/24) had a skilled nurse contribution of a pasted LVN visit narrative dated 10/23/24. There were no SN signatures for attendance of the meeting. The next IDG dated 10/26/24 had the same LVN visit narrative as the SN contribution and again had no SN signatures for attendance. Patient #2 IDG 10/16/24 had a skilled nurse contribution of a pasted LVN visit narrative dated 10/14/24. There were no SN signatures for attendance of the meeting. Patient #3 IDG 10/30/24 SN contribution was a pasted RN visit narrative. No SN signature for attendance. Patient #13 "Initial Orders & IDG Notification" box checked stating "Serves as IDT" dated 11/13/23 many sections blank and NO Signatures from any discipline or MD. IDG dated 11/22/23 no contribution from RN (only contribution was from MSW) NO Signatures. IDT dated 12/6/23 BLANK no contributions, NO signatures. IDG dated 12/20/23 and IDG dated 01/03/24 had only contribution from MSW and NO signatures.

Upon patient record review, 5 of 14 (Patient #1,2,3,13,14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1,2,3,13,14 did not have discipline visit frequencies on the POC.

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7 POC established 1/8/24 did not include any medications from the Medication profile. Patient #9 POC established 6/4/24 did not include medications. Patient #10 POC established 02/21/24 did not include medications (Comfort Kit) that were listed on the comprehensive assessment.

Upon patient record review, 6 of 14 (Patient #2,3,7,9,10,13) 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 #2,3 had oxygen concentrators in the home. Oxygen was not listed on the current POC provided for home visit. Patient #7 POC established 1/8/24 did not include any DME listed on Comprehensive admission assessment (bed, wheelchair). Patient #9 POC established 6/4/24 did not include any DME. Patient #10 POC established 02/21/24 did not include any DME (oxygen). Patient #13 POC established 11/13/23 did not include any DME listed on comprehensive assessment. (Bed)

Upon client record review, 5 of 14 (Patient #1,2,3,13,14) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 Patient #12 contained no evidence that the initial bereavement assessment was completed or updated at the time of death. No evidence of a bereavement plan of care. No evidence of post-death contact or mailings.

Upon patient client record review, 1 of 14 (Patient #2) 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. Patient #2 Upon Home visit observation, the patient folder was for Ensure Hospice. The educational information was Ensure Hospice, the 24 hour number was for Ensure Hospice, however; the copies of admission papers were Well Care Hospice and when the patient was asked how she reaches Well Care Hospice, she did not refer to the folder, she had the correct number on a notebook in her own notes. SN states that she works for both hospices and it was likely a mistake on admission. Agency provided patient with the Well Care patient folder.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the discharge summary includes all required information. •The patient's current plan of care •The patient's latest physician orders •Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care.