Every finding on record at Icare Hospice Services, Inc.

Upon patient record review, 4 of 14 (Patient #1,2,3,5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 1,2,3,5: Initial IDG and all subsequent IDGs did not contain the name or signature of the SC or the RN. There is no evidence to support SC or the RN was present and participated in any IDG meetings or the plan of care development.

Observed in Record Review. In 2 of 2 patient records reviewed, the surveyor noted that the organization did not provides the patient with care, treatment, services according to their individualized plan of care. During record review of HOSV#2, the License Vocational Nurse (LVN) documented the patient blood sugar as 180 on visit dated 10/17/2021 and 184 on visit dated 10/24/2021. Additionally, in HOSRR #1 the LVN documented the patient blood sugar between 162-170 for 3 home visit. According to the patients IDG plan of care the blood sugar is to be maintained between 80-150. However, the LVN failed to follow the plan care by not notifying the RN regarding the elevated blood sugar. This finding was discussed with Director of Patient Services/ Administrator.

Observed in Record Review. In 1 of 5 resident records reviewed, the surveyor noted that the patient record did not contain information that reflects the patient's care, treatment, services. During record review of HOVS#1, the surveyor noted that visit were made by both RN and LVN but only the LVN documentation were in the patient record. Upon discussing it with the Director of Patient Services (DPCS) she stated the RN documentation was completed but has not yet been filed in the patient record. The DPCS was able to provide copies of the RN assessment documentation to the surveyor confirming the date and time when the visit occurred. This finding was confirmed with DPCS/Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, During review of the patient records, it was noted the organization had not ensured the entries in the patient record are authenticated. During record review of HOSV #2, the fall assessment form was fully completed, signed by Registered Nurse but dated 10/12/2021. patient was admitted to organization 10/16/2021. This was confirmed by Director of patient Services/ Administrator.