Every finding on record at No Pain Hospice Care, Inc.

Upon patient record review, 4 of 5 (Patients #1, #2, #3, #4) 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. Patients #1, 2, 3, 4: Comprehensive assessment by the RN listed patient as being short of breath at rest and with exertion. No evidence of goals or interventions addressing this on the plan of care.

Upon patient client record review, 1 of 5 (Patient #1) 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 #1: Psychosocial Assessment had contradictory information related to IHSS community resources. In the section related to ADL, it is marked that the patient receives assistance from IHSS for meals and household chores. In the narrative, it lists that patient was ineligible for those services due to immigration status. Social Worker reports that the entry that the patient has it was in error, that the status was pending.