Every finding on record at Hospice Care Inc

Upon patient record review, 4 of 14 (Patient #4,7,8,10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4,7,8,10, No evidence of primary bereaved person identified. Primary bereaved area left blank.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,9,10) 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., Patient #1,2,3,4,5,6,9,10, No evidence of funeral home identified on initial MSW assessment. No evidence of plan documented in care plan.

Upon client record review, 4 of 14 (Patient #4,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, SC frequency is every certification period. Patient seen 5/21/24 and 8/15/24. Certification period is 5/19/24 to 8/16/24. No evidence visits were completed every certification period. Patient #7, SC frequency is every certification period. Patient seen 3/12/24 and 6/7/24. Certification period is 3/11/24 to 6/8/24. No evidence visits were completed every certification period. Patient #8, MSW frequency 1x/month. Patient was seen on 7/3/24 and 7/30/24. No evidence frequency was followed for 1x/month. SC frequency is every certification period. Patient seen 5/4/24 and 7/30/24. Certification period is 5/2/24 to 7/30/24. No evidence visits were completed every certification period. Patient #9, SC frequency is every certification period. Patient seen 4/27/24 and 7/22/24. Certification period is 4/25/24 to 7/22/24. No evidence visits were completed every certification period.

Upon patient client record review, 6 of 14 (Patient #4,6,7,8,9,10) 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 #4,7,8,9, IDG note on 8/19/24 has no evidence of MSW signature. Patient #6, IDG note on 8/19/24 and 7/8/24, no evidence of MSW signature. Patient #10, IDG note on 8/5, 8/19 and 9/2, no evidence of RN signature.