Every finding on record at Blue Ribbon Hospice Inc

Upon patient record review 1 of 14 (Patient #11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 11: The patient was admitted on 10/3/23, a psychosocial assessment was not completed.

Upon patient record review, 1 of 14 (Patient #13) 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 13: The frequency order for RN visits is entered as 1 visit every 14 days, the patient received an RN visit on 1/8/24, there was no RN visit made after that date, the patient died on 2/8/24.

Upon client record review, 2 of 14 (Patient #11, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 11: The frequency orders for SN visits is entered as 1 x per week effective 10/3/23, there was no visit made the week of 10/8/23 - 10/14/23. Patient 13: The frequency order for RN visits is entered as 1 visit every 14 days, the patient received an RN visit on 1/8/24, there was no RN visit made after that date, the patient died on 2/8/24.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 07: The physician narrative does not include the patient's comprehensive medical information, subjective or objective data to support the terminal illness, or address the unrelated diagnosis of diabetes (the patient utilizes insulin Basaglar QwikPen.)

Upon patient client record review, 1 of 14 (Patient #2) 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 02: SN visits were performed on 1/23/24 and 1/30/24, the documents have not been electronically authenticated by the LVN, the agency policy establishes that documentation must be completed within 48 hours after each visit.