Every finding on record at Holy Redeemer Visiting Nurse Agency

Upon patient record review, 1 of 19 (Patient #12) 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 #12 - POC dated 04/04/2023 did not have Hoyer Lift that patient had in home.

Upon patient record review 3 of 19 (Patient #9, 11, 14) 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 #9 - POC dated 04/06/2023 shower to be completed every visit. Week of 05/01/2023 shower not performed on 05/03/2023 or 05/04/2023 - reason documented not completed was because shower was done on 05/02/2023. Week of 04/17/2023 shower not performed on 04/17 - documented performed on 04/12/2023 and not completed on 04/21/2023 because "not a shower day". Patient #11 - POC dated 02/19/2023 shampoo to be performed 1 x week - week of 04/10/2023 completed 2 x week. Patient #14 - POC dated 05/10/2023 shower to be performed 1 x week - week of 05/15/2023 completed 2 x week.

Upon patient client record review, 1 of 19 (Patient #16) 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 #16 - SN visit note on 04/06/2023 and 05/05/2023 did not have documentation of size of foley catheter inserted.