Every finding on record at At Ease Hospice and Palliative Care, Inc.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Patient was admitted on 9/20/23. During the initial compressive assessment the spiritual care and MSW services identified needs for scheduled visits, there was no problem statements with interventions and goals included in the plan of care.

Upon patient record review, 1 of 14 (Patient #14) 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 #14: Patient's level of care was changed to continuous care on 3/16/23. The plan of care was not updated to include interventions and goals for continuous care services.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Patient was admitted 9/20/23, MSW orders are written for Initial Evaluation within 5 days from admission then every re-cert. MSW made a routine visit on10/20/23.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #7: Patient admitted on 9/25/23, the RN indicated in the comprehensive assessment an "Order received to initiate oxygen at 2 liters per minute via nasal cannula." The note does not indicate who the order was received from. The medication order for oxygen was entered on 10/2/23.