Every finding on record at Ideal Hospice Care, Inc

Upon patient record review, 3 of 14 (Patient #3, 4, 7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3: Aide careplan included task of shower at every visit. Section on dressing not filled out. It is unclear what the dressing tasks are for the aide at each visit. Patient #4: Aide careplan included task of "dress every visit" but "street cloths' and "pajamas/gown" weren't selected. It is unclear which the aide was supposed to do. Patient #7: Aide careplan included task of "pajamas/gown" but didn't include the frequency of "dress every visit". It is unclear how often the aide was supposed to perform this task.

Upon patient client record review, 3 of 14 (Patient #8, 11, 14) 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 #8: SN visit note date 8/20/2024 not electronically signed by clinician. Patient #11: IDG dated 5/23/2024 not electronically signed by MD, RN or SC. Patient #14: IDG dated 2/29/2024 not electronically signed by MD, RN or SC.