Every finding on record at Loving Hands Hospice

Upon patient record review, 1 of 14 (Patient #3) 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 #3: Patient Initial POC contains an order for albuterol 0.083% via inhalation every 6 hours and during home visit a nebulizer was on the patient bedside table. Nebulizer not listed on the POC.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: Initial POC ordered SC at every recert. No evidence of an SC visit prior to 5/8 recert period. No evidence of a missed visit or order to change frequency.

Upon patient client record review, 3 of 14 (Patient #2, 3, 6) 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 #2: Initial POC ordered aide 2x/week. Aide care plan dated 12/28 and 3/21 listed aide 1x/week in error. Patient #3: SC visit on 5/23 not electronically signed by clinician. Patient #6: SN visit on 6/6 not electronically signed by clinician.