Every finding on record at Personal Care Hospice Services, Inc.

Upon patient record review, 2 of 14 (Patient #5,10) 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 #5, Patient is full code status. No evidence full code status addressed in care plan. Patient #10, Patient has no funeral addressed in initial MSW assessment. No evidence this was addressed in care plan.

Upon patient record review, 5 of 14 (Patient #2,3,7,8,14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2, Patient admitted on 12/9/23. On 5/1/24, MSW care plan states complete initial assessment within 5 days. No evidence of updated care plan. Patient #3, Patient admitted on 12/9/23. On 5/15/24, MSW and SC care plans states complete initial assessment within 5 days. No evidence of updated care plan. Patient #7, Patient admitted on 1/27/24. On 5/15/24, MSW and SC care plan states complete initial assessment within 5 days. No evidence of updated care plan. Patient #8, Patient admitted on 12/11/23. On 5/15/24, MSW and SC care plan states complete initial assessment within 5 days. No evidence of updated care plan. Patient #14, Patient admitted on 3/19/24. On 4/3/24, MSW and SC care plan states complete initial assessment within 5 days. No evidence of updated care plan.

Upon client record review, 4 of 14 (Patient #1,5,8,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW documented as declined. Patient was seen on 11/25/23, no evidence of order for visit. Visit was completed as a telephone visit, no evidence of order for telephone visits. Patient #5, SC completed initial assessment on 5/21/24 as telephone visit. No evidence of order for telephone visit. Patient #8, PT order for eval and treat. No evidence of orders for further visits. Patient was seen 2x a week for 3 weeks. Patient #11, SC completed initial assessment on 4/13/24 as telephone visit. No evidence of order for telephone visit.