Every finding on record at Best Hospice Care, Inc

Upon patient record review, 7 of 14 (Patient #2,3,4,6,7,8,9) 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 #2,3,No evidence of care plan for code status of undecided. Patient #4,6,7,8,9, No evidence of care plan for full code status.

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient #3, Home visit completed, walker noted during visit. No evidence of walker documented on POC.

Upon client record review, 2 of 14 (Patient #1,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW frequency 1x/month, visits made on 7/1/24 and 7/30/24. Patient #10, SN frequency documented 1 per for changes in condition, no evidence of frequency.

Upon patient client record review, 1 of 14 (Patient #7) did not have evidence that each patient record contains Advance Directives. Patient #7, Advance Directive was not completed on consent form.

Upon patient client record review, 2 of 14 (Patient #2,5) 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 #2, IDG on 6/15/23, no MSW signature. Patient #5, IDG on 7/25/23, no MSW signature.