Every finding on record at Lenta Hospice Inc.

Upon patient record review, 1 of 5 (Patient 1) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: The comprehensive assessment did not include documentation of the imminence of death. Section on form was left blank.

Upon patient record review, 1 of 5 (Patient 5) 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 equipment and supply needs. Patient 5: Patient received an oral suction machine that was utilized by the hospice nursing staff during the provision of Continuous Care. DME is not on plan of care. Order for its use was present on the plan of care.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 4: RN visit on 9/20/23 documented as follows: "stage III to sacral area noted. Cleansed with NS, pat dry, apply MediHoney then covered with dry dressing q day and prn soilage". There was no update to the plan of care to reflect problems/interventions/goals related to wound or skin integrity.

Upon client record review, 2 of 5 (Patient #4, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: RN visit on 9/20/23 documented as follows: "stage III to sacral area noted. Cleansed with NS, pat dry, apply MediHoney then covered with dry dressing q day and prn soilage". No evidence that MD order for the use of MediHoney was obtained and medication review not completed on medication profile. Patient 5: RN providing CC on 10/22/23 documented " applied lubricating eye drops" during her shift. No evidence that an MD order was obtained for use of this OTC product.