Every finding on record at Immediate Hospice Care

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1 plan of care notes "Sacral wound care irrigate with normal saline, pat dry with gauze, apply Mepilex sacral dressing, calmoseptine to peri wound daily and as needed for soiling. Family to perform wound care as needed". There is no evidence family is taught wound care.

Upon patient record review, 1 of 14 (Patient #1) 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 medications and treatments. Patient 1 plan of care notes "Sacral wound care irrigate with normal saline, pat dry with gauze, apply Mepilex sacral dressing, calmoseptine to peri wound daily and as needed for soiling. Family to perform wound care as needed". SN frequency is 1 X weekly. Wound care orders unclear as to who will perform daily wound care when SN not in the home.

Upon client record review, 2 of 14 (Patient 6 and 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6 and 7 plan of care notes "SN assess vital signs every assessment (temp, BP, HR, RR, Oxygen saturation and pain)". Patient 6 SN notes show no evidence of Oxygen saturation being obtained on 4/21/23, 4/28/23, 5/5/23, 5/12/23, 5/19/23 and 5/26/23. Patient 7 SN notes show no evidence of Oxygen saturation being obtained on 5/2/23, 5/16/23, 5/23/23 and 5/30/23.

Upon client record review, 2 of 14 (Patient 11 and 12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested