Trust Care Hospice, Inc.

“Upon patient record review, 3 of 14 (Patient #3,6,8) 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 #3 - The initial risk assessment completed on 03/18/26 documented that the bereaved was listed as low risk with only one risk factor “exhaustion” listed. This risk assessment did not include the name of the primary bereaved. Patient #6 - The initial risk assessment completed on 02/25/26 documented that the bereaved was listed as low risk with only one risk factor “exhaustion” listed. This risk assessment did not include the name of the primary bereaved. Patient #8 - The initial risk assessment completed on 02/07/26 documented that the bereaved was listed as low risk with only one risk factor “exhaustion” listed. This risk assessment did not include the name of the primary bereaved.”

“Upon patient record review, 3 of 14 (Patient #1,6,8) 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 #1 - The patient’s POLST form showed patient chose to be a full code. There was no evidence of problems, goals, or interventions related to that full code status. Patient #6 - The patient’s medication profile showed patient was taking Eliquis as a blood thinner daily. There was no evidence of problems, goals, or interventions related to the bleeding risk. Patient #8 - The patient’s POLST form showed patient chose to be a full code. There was no evidence of problems, goals, or interventions related to that full code status.”

“Upon client record review, 8 of 14 (Patient #1, 3, 4, 5, 6, 7, 8,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #3 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #6 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patient #8 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the spiritual care coordinator. Patient #10 - The IDG dated 05/02/26 showed no evidence of a plan of care update by the nurse and spiritual care coordinator. Patients 1,3,4,5,6,7,8 showed an IDG was held on 05/02/26, however did not include all discipline signatures as required by the agency process or proof of attendance at the IDG.”

“Upon patient record review 2 of 14 (Patient #2,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2 - The aide plan of care dated 09/08/25 had a frequency order for aide visits one time per week. The week of 04/26/26 - 05/02/26 had documented visits completed on 04/26/26 and 04/30/26 without evidence of an order for an extra visit. Patient #6 - The aide plan of care dated 02/25/26 had a frequency order for aide visits two times per week. The weeks of 04/05/26, 04/12/26, and 04/19/26 had evidence that only one aide visit was completed in each week: 04/07/26; 04/14/26; and 04/21/26. The medical record showed no evidence of a change in frequency or missed visit documentation.”