Every finding on record at Bright Universe Hospice Care Inc

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The Chaplain was accepted by the patient and visited once a month in July, August, September, October and November of 2024. There were no frequencies for the chaplain on plans of care dated 07/28/24 through 10/29/24 therefore, visits were performed without order.

Upon patient record review 1 of 14 (Patient #2) 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 • Consistent with the hospice aide training Patient #2: On 11-02-24 and 11-9-24, the aide documented arrival and departure, staying 1 hour at the patient's home on both days. The aide documented no special concerns as assigned, but there was no evidence of documentation regarding care provided or vital signs as assigned by the RN, and there was no documentation that patient refused care.

Upon patient record review, 1 of 1applicable (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4 On the 9/6/21 aide assignment sheet there is no frequency with the associated tasks of bath, hair care, nail care and housekeeping.

Upon patient record review, 2 of 5 (Patient #4 and 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 #4 The 8/27/21 bereavement assessment contains only the first initial with the last name, credentials and date for the MSW. Patient #5 The 8/27/21 bereavement assessment contains only the first initial with the last name, credentials and date for the MSW.