Every finding on record at Comfortcare Hospice Inc

Upon patient record review, 2 of 5 (Patient #1, 5) 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 1: A POLST form, dated 12.03.2021 was present in the patient record; however, neither sections A nor B were completed which would indicate CPR preference and life sustaining treatment preference. The initial plan of care was not marked to indicate whether or not the patient was DNR or full code status. There was no plan of care developed on admission, or subsequently thereafter, related to advance directives/code status. (corrected onsite) Patient 5: The 10/28/21 certification of terminal illness and the comprehensive nursing assessment, as well as all subsequent skilled nursing visit notes, indicate that the patient is a high fall risk and has a high risk of injury. Patient has an unsteady gait and requires standby assist on ambulation with a walker. The medication list has meclizine PRN for the management of dizziness. However, there was no plan of care developed on admission, or subsequently thereafter, related to falls/safety.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient 1: A POLST form, dated 12.03.2021 was present in the patient record; however, neither sections A nor B were completed which would indicate CPR preference and life sustaining treatment preference. The POLST form must be completed in its entirety to indicate the patient's end of life preferences/advance directives. (corrected onsite)