Every finding on record at Cardea Hospice and Palliative Care

Upon patient record review, 1 of 14 (Patient #10) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #10, RN assessment completed 4/22/22, 5/30/22, 6/17/22, 7/11/22, no updates to the comprehensive assessments within 15 days.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10, RN assessment completed 4/22/22, 5/30/22, 6/17/22, 7/11/22.

Upon patient client record review, 1 of 14 (Patient #13) 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 #13, Comprehensive note signed by the administrator to close note of RN, this note was not signed by RN completing the assessment.