Every finding on record at Angels Touch Hospice Care Inc.

Upon patient record review, 2 of 5 (Patient #1,2) did not have evidence that the patient chooses a health care provider, including an attending physician. Section for the choice of attending physician on the election form was left blank.

Upon patient record review, 1 of 5 records (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 2: The medication profile included Miralax powder with no instructions for a diluent.

Upon patient record review, 1 of 5 records (Patient #2) 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 2: The initial physician orders included Miralax powder with no instructions for a diluent.

Upon patient record review, 3 of 5 records (Patients #1,#4,#5) 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 equipment and supply needs. Patient 1,4,5: The medical record contained nursing documentation upon admission identifying patient in possession of oxygen equipment. There was no evidence of the oxygen equipment included in the plan of care.

Upon patient client record review, 2 of 5 records (Patients #1,#2) did not have evidence that each patient record contains signed election statement in accordance with 418.24. Patients 1: The medical record contains signed election of benefit statements with no evidence of notice of non-covered items or election of attending physician is elected or declined. The segments imbedded in the form that provides options for both issues is empty. Patient 2: The medical record contains signed election of benefit statements with no evidence of notice of non-covered items or election of attending physician is elected or declined. The segments imbedded in the form that provides options for both issues is empty.

Upon patient client record review, 5 of 5 records (Patients #1,#2,#3,#4,#5) 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 1,2,3,4,5: The medical record contains signed consents with identification of planned aide service frequency of twice weekly. There is no evidence of an ordered frequency for aide services by the physician or included in the plan of care. Documentation in physician order states that aide service refused.