Every finding on record at Enseguida Hospice Care Inc.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable #13-Shower was assigned as method of bathing on aide plan of care. Nursing notes document that patient is, "totally bedbound."

Upon patient record review 2 of 14 (Patient #5 and #13) 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 #5-The CHHA documented patient vital signs on visits dated 07/01/24 and 07/23/24. The task of taking vital signs was not assigned on the aide plan of care. #13-Shower was assigned as method of bathing on aide plan of care. The CHHA checked shower not completed, with no documentation as to why task was not completed.

Upon patient client record review, 1 of 14 (Patient #13) did not evidence that each patient record contains physician orders. #13-The patient level of care was advanced to Continuous Care, as documented on nursing notes dated 05/16/23 and 05/17/23. There was no physician order for the change in level of care.

Upon patient client record review, 1 of 14 (Patient #10) 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. #10-The primary diagnosis on the Plan of Care and Certificate of Terminal Illness is documented as N40.0 Benign Prostatic Hyperplasia. The documented primary diagnosis in the Physician narrative on the CTI is Prostate Cancer.