Every finding on record at Complete Care Hospice, Inc

Upon patient record review 1 of 14 (Patient #2) 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 2: The patient has a pureed diet ordered, and required the use of a commercial thickener for liquids. She also has medications ordered for GI comfort. Finally, the board & care staff report that the patient must be sitting up fully during any feeding or when drinking, with the HOB fully elevated. However, this patient does not have a care plan developed related to aspiration risk/swallow safety or GI status. (corrected onsite)

Upon patient record review, 4 of 14 (Patient #2, 8, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 2: The MSW has discipline orders written for PRN only visits. (corrected onsite) Patient 8: The MSW has discipline orders written for PRN only visits. (corrected onsite) Patient 9: The MSW and chaplain have discipline orders written for PRN only visits. (corrected onsite) Patient 10: The MSW and chaplain have discipline orders written for PRN only visits. (corrected onsite)

Upon client record review, 13 of 14 (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13: Visit orders are written correctly, and followed, for routine skilled nursing visits. For example, orders may be written for the skilled nurse to visit a patient 1 x weekly, and either a RN or LVN sees the patient as scheduled each week. However, in addition, a RN is also seeing each patient once every 15 days to complete the required comprehensive assessments. These visits do not have associated visit orders for any patients. (corrected onsite) Patient 1: On 11.24.2023, the chaplain made a visit to the patient with no order from the physician. Patient 6: On 12.06.2023, the MSW made a visit to the patient with no order from the physician.