Every finding on record at Healing Hands Hospice Inc

Upon patient record review 1 of 1 applicable records (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 4: The patient record contained documentation by the aide of dentures being cleaned at all visits 1-24-22, 1-27-22, 1-31-22, 2-3-22, 2-7-22, 2-10-22, 2-14-22. Cleaning dentures was not included in the plan of care.

Upon patient client record review, 1 of 5 records (Patient #4) 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 4: The client record contains a SN note for a visit completed, signed off, and dated by RN 2-15-22. Page 2 of the nursing note is signed and dated on 2-12-22.

Upon client record review, 2 of 2 applicable records (Patient #4,#5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 4: The patient record contains a discharge summary. There was no evidence of a discharge summary being forwarded to the attending physician. Patient 5: The patient record contains a discharge summary. There was no evidence of a discharge summary being forwarded to the attending physician.