Every finding on record at Oc Hospice Care, Inc

Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7 No evidence of spiritual or psychosocial assessment was completed within 5 days of admission.

Upon patient record review 1 of 14 (Patient #7) did not have evidence that the comprehensive assessment takes into consideration the nature and condition causing admission (including the presence or lack of objective data and subjective complaints). Patient #7 No evidence of the nature and condition causing the admission. There initial RN assessment had no documentation of the patient's current health situation which supported the reason for hospice at the time of admission. The assessment had areas not filled out and the summary on the assessment did not indicate why the patient was being admitted at the time.

Upon patient record review, 4 of 14 (Patient #1,2,8,13) 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 #1 -No evidence of spiritual or psychosocial care plan. The patient was receiving chaplain and social worker visits. Patient #2 & 13- No evidence of psychosocial care plan. Patient #8- the terminal diagnosis is atherosclerotic heart disease, no evidence of any nursing problem statements with goals, interventions and progress toward outcomes for heart disease.