Every finding on record at Open Heart Hospice, Inc

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: SOC order dated 1/19/2022 includes LVN visits 3x week. There was no evidence of 3 LVN visits week 1, Two visits occurred with no missed visit for the 3rd LVN visit.

Upon patient record review 1 of 1 applicable records (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4: SOC 1/6/2022 order HHA 2 x week. Only one visit made week 1, with no evidence of a missed visit.

Upon patient client record review, 2 of 5 records (Patient #2, #5) 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: SOC orders for RN Q 14 days. Last RN visit in record 5/22/2022, missing visit for date of 6/5/2022. No evidence of a complete record. Per DCPS she did visit and forgot to chart it, Charting now in place. Corrected on site. Patient 5: Visit dated 2/3/2022 included documentation the patient expired at 1104am. The Report of Death and disposal of controlled drugs included documentation the patient expired 2/4/2022 at 1104am. There is no evidence of a correct and authenticated record. Corrected on site.