Every finding on record at Ahc Home Health of Lehigh Valley, Inc

Upon patient record review, 1 of 5 (Patient #3) 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 #3 - POC dated 03/28/24 did not contain a problem, goals or interventions related to the Foley catheter.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 - POC dated 03/28/24 did not contain orders for Foley catheter but noted catheter on the Initial Assessment and documented catheter would need to be changed monthly.

Upon patient client record review, 1 of 5 (Patient #3) 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 #3 - SN visit note on 03/30/24 and 04/03/24 contained "wound care completed as ordered" did not document the specific care that was provided.