Every finding on record at Golden Canyon Hospice Inc

Upon patient record review, 3 of 5 (Patients #1, 2, 5) 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. Patients 1, 2, 5: The initial comprehensive assessment and physician's CTI indicate that the patient is incontinent of urine. The IPOC indicates that the patient is supplied with diapers due to incontinence. The SN's initial assessment includes a Braden scale indicating that the patient is occasionally moist. However, there has not been a care plan initiated or developed including goals and interventions related to the patient's GU status or risk for skin breakdown. (corrected onsite)

Upon patient record review and direct observation, 1 of 5 (Patient #2) 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 equipment and supply needs. Patient 2: The initial comprehensive assessment, the SN indicates that the patient has a cane/crutches/walker, but it is not specified which piece(s) of DME the patient utilizes. On the CTI narrative, the physician states the patient utilizes a walker. On direct observation during the home visit, the patient utilizes a walker. However, the walker is not included on the initial plan of care. (corrected onsite)