Every finding on record at A-Z Hospice Inc

Upon patient record review 4 of 11 (Patient #4,5,6,7) 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, 5, 6, 7 Spiritual Care was declined, RN assessment incomplete with spiritual assessment, missing documentation of religion.

Upon client record review, 3 of 11 (Patient #2,3,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 SN frequency ordered as 2x/week. SN visit completed 1x/week on 9/10/22, 9/24/22 and 10/8/22. Patient #3 SN frequency ordered as 2x/week. SN visit completed 1x/week on 9/8/22 and 9/22/22. Patient #7 SN frequency ordered as 1x/week. SN visits completed twice in one week on 9/11/22 and 9/16/22.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 MSW brought soap and paper towels in a department store bag. Upon arrival in home MSW went into bathroom and set her purse on the bathroom floor rug without a barrier and placed her department store bag on the sink without a barrier. After completion of washing her hands MSW bought bag and purse into patient bedroom and placed on dressing without barrier.

Upon patient client record review, 7 of 11 (Patient #1,2,3,4,5,6,7) 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 #1 MSW assessment on 10/18/22, note was not signed by MSW. Policy is for these to be signed within 30 days. Patient #2 IDG on 8/25/22, 8/31/22, 9/14/22 missing MD signature. Policy is for these to be signed within 30 days. Patient #3 IDG on 8/25/22, 8/31/22, 9/14/22 missing MD signature. Policy is for these to be signed within 30 days. Patient #4 IDG on 8/31/22, 9/14/22 missing MD signature. Policy is for these to be signed within 30 days. Patient #5 IDG on 9/14/22, 9/28/22 missing MD signature. Policy is for these to be signed within 30 days. Patient #6 IDG on 8/31/22, 9/14/22, 9/28/22, 10/12/22 missing MD signature. Policy is for these to be signed within 30 days. Patient #7 IDG on 8/21/22 no SC signature, 8/31/22 no RN and no SC signature, 9/14/22 no SC signature. Policy is for these to be signed within 30 days.