Every finding on record at Lakeshore Hospice Inc

Upon patient record review, 5 of 13 (Patient #4, #5, #7, #8, #9) 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 #4: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 12/5/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #5: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 10/7/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #7: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 2/22/23. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #8: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 11/4/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #9: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 6/4/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient.

Upon patient client record review, 1 of 13 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The EOB was signed by the caregiver. The date on the EOB and the SOC date were not legible. The EMR indicates the patient's SOC was 12/17/22 and the DPCS verified the SOC date was 12/17/22.

Upon patient client record review, 5 of 13 (Patient #7, #8, #9, #12, #13) 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 #7: The nursing comprehensive assessment was not signed or dated by the clinician. The document was not authenticated or dated in accordance to the agency policy. Patient #8: The nursing comprehensive assessment was not signed or dated by the clinician. The document was not authenticated or dated in accordance to the agency policy. Patient #9: The nursing comprehensive assessment was not signed or dated by the clinician. The document was not authenticated or dated in accordance to the agency policy. Patient #12: The nursing comprehensive assessment was not signed or dated by the clinician. The document was not authenticated or dated in accordance to the agency policy. Patient #13: The spiritual assessment was not signed or dated by the clinician. The document was not authenticated or dated in accordance to the agency policy.