Every finding on record at By Grace Hospice LLC

Upon patient record review, 1 of 6 (Patient #2) 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: Patient's hospice diagnosis was Lung Cancer, but there was no plan of care for respiratory opened on plans of care dated 1-5-23, 1-19-23, 2-2-23 and 2-16-23.

Upon patient client record review, 2 of 5 (Patient #2, #3) did not have evidence that all entries are legible, clear, and complete, in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2: Informed Consent/Election of Benefits Section: Services/Rights/Hotline/Policy and Procedures, dated 12-30-22, no information was documented in regard to services (RN, MSW, Aide) accepted by patient. Patient #3: Request for Notification of Hospice Non Covered items was signed and dated, but check boxes that indicated whether or not patient requested to receive notification were not filled in.