Concierge Hospice Care

“Upon patient record review, 1 of 14 (Patient #10) 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 10: The patient was admitted on 06/05/25, there is no evidence that a bereavement assessment has been completed.”

“Upon patient record review, 5 of 14 (Patient #3,6,7,8,10) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 3: The POC dated 01/21/26 contains an order for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 6: Current POC dated 01/19/26 includes an order for Aspirin, there is no evidence of a risk for bleeding with appropriate goals and interventions. Corrected on site, POC updated. Patient 7: Current POC dated 01/19/26 includes an order for Aspirin, there is no evidence of a risk for bleeding with appropriate goals and interventions. Corrected on site, POC updated. Patient 8: RN visit note dated 1/15/26 notes “a small sore on (L) leg, the sore was cleaned , triple antibiotic was applied and covered with clean dressing.” There is no evidence of a skin integrity care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 10: The most recent POC dated 01/19/26 includes and order for Clopidogrel. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated.”

“Upon client record review, 3 of 14 (Patient #5,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Patient was admitted 12/13/25. Social work visit frequency is ordered weekly. Initial psychosocial was completed 12/16/25 and a SW visit is documented 01/20/26. There is no evidence to support weekly frequency. Patient 7: Current POC dated 01/19/26 includes orders for Spiritual care frequency of 1x weekly and 3prn. Visits documented for 11/19/25 & 01/22/26. There is no evidence that weekly visits were made and no missed visits noted. Patient 8: Visit note dated 1/15/26 notes “a small sore on (L) leg, the sore was cleaned , triple antibiotic was applied and covered with clean dressing.” There is no evidence of orders for wound care. Corrected on site, orders obtained.”

“Upon patient record review, 4 of 14 (Patient #1,2,4,9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Most current POC does not include evidence of frequencies of tasks including: Encourage fluids as tolerated if not contraindicated and change patient linens. Corrected on site, POC updated. Patient 2: Most current Aide POC dated 10/30/25 does not include frequencies of tasks including: record bowel movement and dressing. Corrected on site, POC updated. Patient 4: Most current Aide POC dated 12/26/25 does not include frequencies of tasks including: dressing and change patient linens. Corrected on site, POC updated. Patient 9: Most current Aide POC dated 12/26/25 does not include frequencies of tasks including: turn and reposition, record bowel movements and dressing. Corrected on site, POC updated.”