Every finding on record at Zenith Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #3) 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 #3: The patient's hospice diagnosis was Cerebral Infarction, but there was no care plan documented for assessment or interventions for Neuro issues.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: The plan of care dated 03-05-25 and 03-18-25 indicated MSW and Spiritual care were ordered once per month. There was no evidence of visits by the MSW or Chaplain in March.

Upon patient record review, 4 of 14 (Patient #3,#5,#9,#13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: On the Informed Consent/Election of Hospice Benefits signed 10-18-24, there was no evidence of a date for the start of care. Additionally, the Required Signatures for Election of the Hospice Benefit was incomplete with no evidence of an NPI or Address for the chosen attending physician. Patient #5: There was no evidence the Informed Consent/Election of Hospice Benefit signed 11-19-24 included the address or NPI of the chosen attending MD. Additionally, there was no evidence the Required Signatures for Election of the Hospice Benefit signed 11-19-24 contained a start date. Patient #9: There was no evidence the Informed Consent/Election of Medicare Benefits included start date. Patient #13: There was no evidence of an address or NPI number for the chosen attending physician was documented on the Required Signatures for Election of the Hospice Benefit signed 11-01-24.

Upon patient record review, 6 of 14 (Patient #1,#6,#7,#8,#10,#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. Patient #1,#6,#7#8,#10,#14: There was no documented evidence the IDG assessed the ability of the patient or family to administer medications.