Wings of Hope Hospice, Inc.

“Upon patient record review 2 of 15 (Patient #6, 9) 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 #6 - Patient was admitted on 06/26/25. The medical record showed the MSW did not complete the psychosocial comprehensive assessment until 07/26/25. Patient #9 - Patient was admitted on 07/04/25. There was no contact made by the MSW to complete the psychosocial comprehensive assessment until 07/25/25. The medical record showed the comprehensive was completed on 07/29/25.”

“Upon patient record review 1 of 15 (Patient #5) 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 #5 - Patient was admitted on 07/07/25. There was no evidence that a spiritual comprehensive assessment was completed. There was no evidence that the components of the spiritual comprehensive assessment were captured on the nursing or psychosocial comprehensive assessment.”

“Upon patient record review, 2 of 15 (Patient #1, 9) 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 - Patient was admitted on 11/20/25. There was no evidence that the initial bereavement risk assessment was completed by any discipline. Patient #9 - Patient was admitted on 07/07/25. There was no evidence that the initial bereavement risk assessment was completed by any discipline.”

“Upon patient record review, 2 of 15 (Patient #6, 13) 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 #6 - The medication profile showed patient was taking Farxiga 10 mg daily for diabetes management. There was no evidence of problems, goals, or interventions related to the endocrine system initiated. Patient #13 -The medication profile listed aspirin daily as a blood thinner. There was no evidence of problems, goals, or interventions related to bleeding risk. The same profile also listed patient taking Januvia 100 mg daily and novulog 100u/ml take 5 u three times per day along with Lantus 15u q hs. There was no evidence of problems, goals, or interventions related to the endocrine system initiated.”

“Upon patient record review, 2 of 15 (Patient #1, 15) 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 - The medical record showed an order dated 11/20/25 for MSW and chaplain visits to be 1 time per month with 2 prn visits in 90 days. There was an updated order dated 12/22/25 for the frequency of both those disciplines to “change to prn.” There was no evidence of the frequency of those visits. Patient #15 - The medical record showed an order dated 05/06/25 for MSW visits to be 1 time per month with 2 prn in 90 days. There was an updated order dated 05/26/25 stating “change MSW visits to prn.” There was no evidence of the frequency of those visits.”

“Upon patient record review, 2 of 15 (Patient #1, 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 #1 - The comprehensive nursing assessment dated 11/20/25 and subsequent nursing assessments listed patient as incontinent of bowel and bladder at times and utilizes diapers. Patient is also utilizing oxygen prn and a nebulizer. There was no evidence of incontinent, nebulizer or oxygen supplies listed on plan of care. Patient #13 - The nursing comprehensive assessment dated 05/28/25 and subsequent assessments, documented patient was incontinent of bowel and bladder. There was no evidence of incontinent supplies listed on the patient’s plan of care.”

“Upon client record review, 1 of 15 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 - The initial plan of care dated 07/11/25 contained an order for a volunteer 1 time per week for socialization. There was no evidence of visits or missed visit documentation for the weeks of 11/24/25 or 12/01/25. Patient #15 - Patient was admitted on 05/06/25. The MSW contacted the patient on 05/10/25 via phone call and documented the psychosocial comprehensive assessment on that date. There was no evidence of an order for a phone call/telehealth visit for the comprehensive assessment.”

“Upon client record review, 4 of 15 (Patient #10, 11, 12, 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 Patient #10 - There was no evidence in the medical record that the discharge summary was sent to the patient’s attending physician when the patient revoked hospice service on 09/15/25. Patient #11 - There was no evidence in the medical record that the discharge summary was sent to the patient’s attending physician when the patient was discharged from hospice due to extended prognosis on 12/22/25. Patient #12 - There was no evidence in the medical record that the discharge summary was sent to the patient’s attending physician when the patient revoked hospice service on 10/20/25. Patient #13 - There was no evidence in the medical record that the discharge summary was sent to the patient’s attending physician when the patient revoked hospice service on 08/13/25.”