Every finding on record at Catskill Area Hospice and Palliative Care Inc

Based on clinical record review and staff interview the hospice failed to ensure in two of sixteen records (Patient # 2 and 6) an individualized and complete physician Plan of Care (POC) was developed to meet the needs of the patient. Failure to develop a patient specific individualized and complete plan of care has the potential to result in unmet patient needs and negative patient outcomes. --- Findings: Patient # 2 (start of care 07/20/2023) has diagnoses of Unspecified Severe Protein-Calorie Malnutrition and Chronic Osteomyelitis with Draining Sinus, other site. The physician's POC for certification period 07/20/2023 through 10/17/2023 contains an order for: Hydrocortisone 1% Topical Cream, small amount, three times daily as needed. The order is incomplete as it is missing an anatomical location to apply the cream. Patient # 6 (start of care 04/14/2022) has diagnoses of Hypertensive Heart Disease with Heart Failure and Chronic Combined Systolic (Congestive) Heart Failure. The physician's POC for certification period 06/08/2023 through 08/06/2023 and certification period 08/07/2023 through 10/05/2023 contain orders for: Camphor/Menthol/Methyl Salicylate 3.1% - 16% - 10% topical gel, thin film, daily as needed. The order is incomplete as it lacks an anatomical location to apply the cream. Nitroglycerin 0.4 milligram sublingual tablet. Every five minutes as needed. The order is incomplete as it lacks maximum dose to take and instructions on what to do if relief is not achieved. The findings were confirmed on 09/12/2023 at 3:45 PM with the Director of Quality Assurance Performance Improvement and Compliance and Clinical Office Director; no additional evidence was provided.