Every finding on record at Comfortzone Hospice Inc

Upon patient client record review, 2 of 14(Patient #13, #14) 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: On 11-25-24, in the narrative portion of the nursing assessment, the RN wrote, "A supervisory evaluation was completed with the PCG.....expressed satisfaction with the LVN." However, the supervisory portion of the assessment was not complete and there was no evidence of an LVN visit during the patient's time on Hospice. Patient #14: On 11-17-24, in the narrative portion of the nursing assessment, the RN documented, "A supervisory evaluation was completed with the PCG...Family expressed satisfaction with the LVN....approach and willingness to educate." However, the supervisory portion of the assessment was not completed and there was no evidence of an LVN visit during the patient's time on Hospice care.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1 Oxygen was not included on medication profile.

Upon patient record review, 2 of 5 (Patient #1,2) 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: This patient had a bed, oxygen concentrator, bedside commode and wheel chair. These were not included on the Plan of Care or ordered by MD. Patient #2: This patient had a bed and walker. These were not included on the Plan of Care or ordered by MD.

Upon patient client record review, 2 of 5 (Patient #1 and #3) 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. Patient #1 and #3 MSW initial assessment date had double typescript in area for date that was not clear enough to read.