Every finding on record at Peace & Harmony Hospice Care Inc

Upon patient record review 1 of 5 (Patient #5) 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 #5: SC comprehensive assessment completed on 5/18 (day 7)

Upon patient record review, 2 of 5 (Patient #2, #5) 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 #2: Plan of care dated 12/8 listed goal of "patient will have BM every other day by next IDG meeting. Patient will have no episodes of vomiting by next IDG. Nausea will be controlled by medications prescribed by MD by next IDG meeting. No evidence of any medications being ordered for nausea or constipation. Comprehensive nursing assessment completed 12/8 listed that patient denied nausea and had BM that day. No evidence in the patient chart to support that nausea and constipation are an active problem. Patient #5: Plan of care dated 6/30 listed goal of "patient will have BM every other day by next IDG meeting. Patient will have no episodes of vomiting by next IDG. Nausea will be controlled by medications prescribed by MD by next IDG meeting. No evidence of any medications being ordered for nausea or constipation. Comprehensive nursing assessment completed 6/30 listed that patient denied nausea and had BM that day. No evidence in the patient chart to support that nausea and constipation are an active problem.

Upon patient client record review, 2 of 5 (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: POC and medication profile dated 12/8 contained a typo. Both listed Naproxen/esomeprazole magnesium 400mg/20mg 1 tab po daily as needed for "pan"/GERD. Should have been "pain". Patient #5: POC and medication profile dated 6/30 contained a typo. Both listed aspirin as an "nticoagulant". Should have been "anticoagulant".