Every finding on record at First Response Hospice Care

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 SCP visit frequency order dated 2/28/25 are 1x/recert period, no evidence of visit made for BP #2.

Upon patient client record review, 1 of 14 (Patient #2) 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 #2 SN visit on 6/11/25 noted that a supervisory visit was completed for LVN, however there is no evidence of any LVN visits made.

Upon patient record review 2 of 5 (Patient #3 and 4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3: There is no evidence in the record that the Chaplain completed the spiritual comprehensive plan of care. Patient #4: There is no evidence in the record that the Chaplain and MSW completed the comprehensive assessment.

Upon client record review, 3 of 5 records (Patient #1, #2, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The plan of care reflects SN frequency of 1 time a week. No evidence of a nursing visit the weeks of 5/29 and 6/5. Patient #2: The plan of care reflects SN frequency of 1 time a week. No evidence of a nursing visit for the week of 5/22. Patient #4: At admission on 2/18, documentation in the record states that the nursing frequency would be "daily during continuous care". There is evidence of only 1 other nursing visit on 2/19 following the admission. There were no other SN visit notes in the record, with the exception of the Death note on 2/24. No order for the nursing frequency was obtained.

Upon patient record review 1 of 1 applicable (Patient #5) 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 #5: There were orders for aide to visit 2xweek; however an aide visit was missed week of 5/3.