Every finding on record at Montclair Horizon Hospice Inc.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 was admitted 11/2/21 with primary hospice diagnosis of Heart Disease and comorbidity of IDDM with 11/2/21 order for Metformin and Humulin Insulin N. There was no evidence of goals, problems, and interventions associated with IDDM included in Care Plan.