Every finding on record at Comfort Choice Hospice Care, Inc

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4: No evidence of an initial SC comprehensive assessment in the patient file.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: RN Comprehensive assessment lists patient has cane and walker. DME not listed on the POC. Patient is incontinent. No incontinence supplies listed on the POC.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: POC ordered LVN 1xwk. No evidence of an LVN visit week of 5/26/24 or 6/2/24.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #4: CTI dated 4/4/24 Physician Brief Narrative statement was left blank.

Upon patient client record review, 1 of 14 (Patient #4) 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: MSW initial evaluation incomplete. Contains a narrative but other documentation sections are blank.