Every finding on record at Ennoble Hospice PA, LLC

Upon patient record review 1 of 14 (Patient 7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7: Pt admitted 11/20/23 and the psychosocial assessment was completed on 11/26/23.

Upon patient record review, 3 of 14 (Patient 1,5,7) 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: Patient 1 and 5: The medication profiles contain "Miralax 17 dose daily". There is no unit of measure and no diluent. Corrected on site. Patient 7: The SN documented in the comprehensive assessment 11/20/23 "Pt taking furosemide 1/2 tab daily". Furosemide is not on the medication profile. Corrected on site.

Upon patient record review, 5 of 14 (Patient 1,4,5,7,14) 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 medications and treatments. Patient 1 and 5: The POC contains "Miralax 17 dose daily". There is no unit of measure and no diluent. Corrected onsite. Patient 4: The comprehensive assessment shows evidence of pt having a foley catheter. There is no evidence of an order for the foley. Corrected onsite. Patient 7: The SN documented in the comprehensive assessment 11/20/23 "Pt taking furosemide 1/2 tab daily". There is no evidence of an order for furosemide. Corrected on site. Patient 14: The POC contains an order to "Insert Foley 16 fr w 10cc balloon. Replace every 30 days. Flush Foley every 10 days is sediment is in tubing". There is no order for what to flush the Foley with.

Upon client record review, 2 of 14 (Patient 5,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The nurse documents on 11/14/23 and 11/25/23 "Barrier cream applied to sacrum". There is no evidence of an order for barrier cream. Corrected on site. Patient 13: The nurse documents on 11/6/23 barrier cream being applied to a new skin tear. There is no evidence of an order for barrier cream.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 8: The nurse documented on 11/16/23 a fall being reported and the pt getting staples. There was no evidence of an incident report being completed.

Upon patient record review 1 of 14 (Patient 13) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 13: The medical record contains documentation by the aide a visit being made on 10/26/23 from 14:00-14:00 with a narrative "Recognize and report any changes in patient skin condition daily-Done". Spoke with administrator, this was a missed visit. There was no documentation that this was a missed visit and it was not documented correctly.

Upon patient client record review, 3 of 14 (Patient 1,5,14) 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 1: The comprehensive assessment on 11/3/23 the nurse documents "AAOx1" and "w" in the narrative, these are not approved abbreviations. Patient 5: The comprehensive assessment on 11/7/23 the nurse documents "AAOx1" in the narrative, this is not an approved abbreviations. The POC contains a goal of "Pt to maintain pain scale of ____or less. There is to be in a number on the blank line. Patient 14: The nurse documents on 8/5/23 "Pt on 2l no as needed".

Upon client record review, 5 of 14 (Patient 10,11,12,13,14) did not have evidence that the discharge summary includes all required information. Patient 10,11,12,13,14: The discharge summary did not include: a summary of the patient's stay, including treatments, symptoms and pain management, the patient's current plan of care.

Upon client record review, 1 of 14 (Patient 8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 8: The POC contains an order for wound care though does not state who is to perform the wound care.