Every finding on record at Humane Love Hospice

Upon patient record review, 1 of 5 (Patient #2) 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. Patient #2: The patient was admitted with a hospice diagnosis of End Stage Heart Disease the comprehensive nursing assessment dated 6-12-22 indicated the patient complained of pain in the chest and back and complained of poor appetite and a 20 pound weight loss. There is no evidence of care plan problems, goals, or interventions related to pain/ discomfort or nutrition.

Upon patient client record review, 4 of 5 (Patient #1,#2,#3,#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. Patient #1: On the comprehensive nursing assessment dated 6-12-22 the nurse documented the MSW frequency would be 1 time within 5 days and then 1 time per month the documentation also contains that the MSW services were declined (discrepancies in documentation). Corrected on site. Patient #2: The medical record included the bereavement risk assessment visit dated 6-12-22 with no signature of the clinician who completed the assessment. Corrected on site Patient #3: The comprehensive nursing assessment dated 6-12-22 indicated a referral for volunteer services to run errands; there is a discrepancy in the nursing narrative stating the patient refused volunteer services; the frequency on the plan of care dated 6-12-22 indicated the patient declined volunteer services (discrepancies in documentation). Corrected on site. Patient #5 The medical record contained documentation by the Medical Director on the Certification for Terminal Illness narrative dated 4-17-22 which indicated the patient was admitted to "Celestial Care Hospice" however the patient was admitted to Humane Love Hospice on 4-17-22.