Every finding on record at Blue Shield Hospice

Upon patient record review, 2 of 14 (Patient #13,14) 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 #13 physician order to change level of care to Continuous Care 7/8/24 which was initiated @1430 and ended 7/09/25 at 0309 when patient passed. There was no update to the plan of care with this change of condition/ level of care change. Patient #14 readmitted to this hospice 02/15/25. During admission process a POLST was completed by the daughter with the Hospice staff that elected CPR/Full Code. The Plan of care also showed Full Code Status. LVN visit note 2/27/25 @ 1100 narrates, "patient in final stages of life. Family aware and focused on comfort care". The narrative also notes much education provided and understanding by the family. There was no evidence of updated plan of care, nor updated code status. The patient passed later that day with an appropriate death visit.

Upon personnel record review, 1 of 13 (Personnel #5 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5 competency only stated "shower/Tub" and "Shampoo". Competency did not include "Sponge" bath or "Shampoo, Sink, Tub, and bed".