Every finding on record at Grand Hospice Inc

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 7: No evidence that SN visits for the month of November were completed. All visit documentation for that month were blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver.

Upon patient record review, 3 of 14 (Patient #2,4,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: No evidence that SN visit for the week of 10/27/2024 was completed. Plan of care has SN frequency ordered as one visit a week. No evidence that the visit was refused by the patient/caregiver. Patient 4: No evidence that a SN visit for the week of 11/24/2024 was completed. Plan of care has SN frequency ordered as one visit a week. No evidence that the visit was refused by the patient/caregiver. Patient 7: No evidence that SN visits for the month of November were completed. All visit documentation for that month were blank, with only time in/time out documented. No evidence that the visits was refused by the patient/caregiver.

Upon patient record review, of 1 of 5 (Patient #5) 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 #5 - The Election of Benefits indicated the start of care date as 8/5/21 and the patient and Hospice RN signatures were dated 8/5/21. Additional admission forms were dated 8/5/21. The Patient Consent for Care and Services Agreement the patient and Hospice RN signatures were both dated as 8/15/21. There were no other dates on the form.