Every finding on record at Preferred Hospice

Upon patient record review, 1 of 14 (Patient #3) 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 medications and treatments. #3-SN applying Xeroform to wound. There is no order for Xeroform or petrolatum impregnated gauze.

Upon patient client record review, 2 of 14 (Patient #3 and #13) 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. #3-SN notes on 07/24/24 and 07/31/24 contained conflicting wound documentation: Pressure ulcer is documented, "Site-Sacral area Stage III. Stage- I." #13-SN copy/pasted Narrative from visit noted dated 03/13/24 onto SN Narrative for visit performed 03/20/24. The Narrative note was copied verbatim.