Every finding on record at Bliss Hospice, Inc.

Upon patient record review, 1 of 11 (Patient #4) 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 #4, Patients primary admitting diagnosis of Heart Disease, Missing cardiac care plan.

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, 2, 3 LVN did not sanitize hands every time LVN went in and out of bag.

Upon patient record review 3 of 5 applicable (Patients #1,2,3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1 Aide visits on 10/12/22, 10/15/22, 10/19/22, 10/21/22, Care Plan directed to provide street clothes, dress, feeding assistance. These tasks were not completed or discussed with RN for reason for not being completed. Patient #2 Aide order effective 8/24/22 for 2x/week, no visits week of 8/24/22. Patient #3 Aide documented on 9/9/22, 9/12/22, 9/16/22, 9/19/22, BM which was not directed on Care Plan.

Upon patient client record review, 3 of 11 (Patient #6,8,11) 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 #6, LVN has no signature on visit notes from 9/23/22, 10/2/22, 10/9/22, 10/13/22. Patient #8, RN has no signature on visit note of 10/17/22. Patient #11, LVN has no signature on visit notes from 7/4/22, 7/11/22.