Every finding on record at Otium Hospice Care, Inc

Upon patient record review, 2 of 14 (Patient #2 &9) 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 2 & 9: Medication lists and MD orders reflect Oxygen use. No evidence found of Interventions and Goals associated with Oxygen use, education, or safety precautions.

Upon patient record review, 2 of 14 (Patient #6 & 7) 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. Patients 6 & 7: Initial assessment documents use of cane and walker. No evidence of these aides found on plan of care.

Upon patient client record review, 1 of 14 (Patient #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 6: Admission Plan of Care lists patient diet as regular. All nursing visit documentation reports diet as mechanical soft.