Zenith Hospice

“Upon patient record review, 4 of 14 (Patients #4, 6, 7, and 9) did not contain evidence that the Comprehensive Assessment included a Bereavement Risk Assessment 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 Risk Assessment is incorporated into the Plan of Care and is considered in the Bereavement Plan of Care: Patients #4, 6, 7, and 9: These records did not contain documented evidence that the SOC Comprehensive Assessment included a Bereavement Risk Assessment component.”

“Upon patient record review, 6 of 14 (Patient #1,#2,#3,#4,#6,#10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: The POC included, “Offer Glucerna supplement as ordered.” This is not an individualized/complete order, as it does not include an amount or frequency. The POC also included, “Patient instructed to use warm/cold compresses”, without details such as the frequency, duration, purpose of, etc ... Patient #2: The 04/03/25 IDG POC included, “Offer Ensure supplement as ordered.” This is not an individualized/complete order, as it does not include an amount or frequency. Patient #3: The POC included, “Offer Ensure supplement.” This is not an individualized/complete order, as it does not include an amount or frequency. The POC included, “Apply Mupirocin topical cream 2%. Apply topically on ‘affected area’ two times a day”. There is no identified area of the body/purpose for which to apply this. Patient #4: The 04/03/25 IDG POC included, “Offer Glucerna supplement as ordered.” This is not an individualized/complete order, as it does not include an amount or frequency. Patients #6 and 9: These POC(s) included, “Provide supplements as ordered.” This is not an individualized/complete order, as it does not include an amount or frequency. Patient #10: The POC included, “Offer Glucerna supplement.” This is not an individualized/complete order, as it does not include an amount or frequency.”

“Upon patient record review, 4 of 14 (Patients #2, 3, 5, and 7) did not contain evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #2: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits in July, September, and December 2024, and February 2025 (only at the beginning of each new 90/60 certification period; which was based upon a 06/29/24 frequency order). Patient #3: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 04/30/24, 07/24/24, 10/22/24, 12/21/24, and 02/13/25. Patient #5: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 01/27/25 and 03/04/25. No visits made in February 2025. Patient #7: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 02/18/25, but not visits in March 2025.”

“Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that an Aide Skills Competency had been conducted which included all CMS requirements: Personnel #8: DOH 01/01/25. An Aide Skills Competency was conducted on 01/01/25. However, the following skills were not evaluated for: Normal Range of Motion and Positioning. ROM was assessed for ‘verbally’, and the line item for Positioning had been left blank. The remaining subject areas which may be evaluated through written examination, oral examination, or after observation of a Hospice Aide with a patient or with a pseudo-patient as part of a simulation were not assessed for: • Basic elements of body functioning and changes in body function that must be reported to an Aide’s supervisor • The physical, emotional, and developmental needs of, and ways to work, with the populations served by the Hospice.”

“Upon patient record review, 7 of 14 (Patients #1, 2, 3, 7, 8, 9, and 10) did not contain evidence that each patient record contained: A signed Hospice Election of Benefit (EOB) Statement in accordance with 418.24 and/or the provision of a Patient Notification of Hospice Non-Covered Items, Services, and Drugs; when requested: Patients #1, 7, 8, and 10: These EOB(s) did not contain documented evidence of these patients’ choice to designate an Attending Physician. This section had been left blank. These EOB(s) reflected that these patients wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient. Patient #2: The EOB did not contain documented evidence of the patient’s choice to designate an Attending Physician. This section had been left blank. Patient #3: The EOB reflected that the patient wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient. Patient #9: The EOB did not contain documented evidence of the patient’s choice to designate an Attending Physician. The patient had checked that they did wish to designate and Attending. However, the section to enter the Physician’s name had been left blank. The EOB reflected that the patient wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient.”

“Upon patient record review, 4 of 14 (Patients #1, 3, 4, and 8) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #1: The 03/18/25 admission Consent documented, “The patient has no Advance Directives.” However, the POLST dated 03/18/25 included an order for DNR. Unclear documentation. Patient #3: The 04/26/24 admission Consent documented, “The patient has no Advance Directives.” However, the POLST dated 04/26/24 included an order for DNR. Unclear documentation. Patient #4: On the 04/01/25 CTI, the Medical Director notes, “Patient is a Full code.” However, the POLST dated 01/01/25 includes an order for DNR. Unclear documentation. Patient #8: The 03/12/25 admission Consent documented, “The patient has no Advance Directives.” However, the POLST dated 03/12/25 included an order for DNR. Unclear documentation.”