Every finding on record at Empyrean Hospice and Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #4) 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 #4, No evidence of funeral home identified on the psychosocial initial assessment funeral home was not documented on the plan of care.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3, Aide note on 2/27/25 documented BM for the patient. No evidence on the patient care plan to document BM.

Upon patient record review, 2 of 5 (Patient #2,#5) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring #2,#5- The plan of care orders contain oxygen but it is not listed on the medication profile.

Upon patient record review, 1 of 5 (Patient #4) 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. #4- The patient has CHF and is on oxygen as needed but there are no goals or interventions for safe oxygen and equipment use.

Upon patient client record review, 2 of 5 (Patient #1,#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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. #1- The patient has an order for oxygen as needed. On 2/2/22 and 2/16/22 SN did not specify if the oxygen saturation was obtained on room air or oxygen. In addition, on 2/16/22 SN documented the patient is on a regular diet with aspiration precautions. The plan of care contains mechanical soft diet with aspiration precautions. #3- On 1/11/22 and 2/7/22 the RN documents supervisory done. The documentation does not include who was being supervised and the supervision check sheet was left blank.