Trilogy Hospice, Inc.

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient#1,#2,#3: Patient primary language was not English. There was no evidence that Patient rights and responsibilities we provided in a written language the patient understands. Corrected on site.”

Rule L0502. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c))

“Upon patient record review 1 of 14 (Patient #4) 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#4: There is no evidence of an initial spiritual assessment completed for patient.”

Rule L0524. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1))

“Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#9: There is no evidence RN included wound measurements in comprehensive assessment between 5/2/25-5/30/25.”

Rule L0540. Standard-level.

Review of the plan of care (42 CFR 418.56(d))

Rule L0552. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

Rule L0555. Standard-level.

Coordination of services (42 CFR 418.56(e)(3))

“Upon patient record review 2 of 14 (Patient #2, #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#2: The record indicates an order was placed on 4/9/25 for podiatry. There is no evidence of follow- up on this order documented. Patient#3: The record indicates an order was placed on 2/27/25 for podiatry. There is no evidence of follow- up on this order documented.”

Rule L0556. Standard-level.

Coordination of services (42 CFR 418.56(e)(5))

“Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#9: There is no evidence on any IDG meeting of documented collaboration of care and communication with the wound care company providing debridement care of the stage IV sacral wound.”

Rule L0558. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient#3: The record indicates there is a physician narrative for recertification starting 5/6/25. However, there is no evidence of physician signature on recertification for 5/6/25-8/13/25.”

Rule L0668. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient record review, 1 of 14 (Patient #8) 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#8: The record indicates patient signed form for full code. However, the electronic medical record shows patient is DNR. Corrected on site.”

Rule L0679. Standard-level.