Every finding on record at Primericare Hospice LLC

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 5 (Patient #4) 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. Patient #4: The clinical record on 8-10-22 contains a narrative by the RN “Patient is ambulatory with a walker due to easy fatigability, poor endurance, shortness of breath and unsteady gait.” There is no walker on the POC.

Upon patient client record review, 4 of 5 (Patient #1,#2,#3,#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 #1: The POC on 8-16-22 contains: “Pt/Cg will demonstrate knowledge of medication and diet.” Cg is not an approved abbreviation. Corrected on site. Patient #2: The POC on 8-19-22 contains: “Pt/Cg will demonstrate knowledge of medication and diet”. "Pt/Cg demonstrates correct use of medication”. Cg is not an approved abbreviation. Corrected on site. Patient #3: The POC on 8-20-22 contains: “Pt/Cg demonstrates correct use of medication”. Cg is not an approved abbreviation. Corrected on site. Patient #5: The POC on 8-1-22 contains: “Pt/Cg demonstrates correct use of medication”. Cg is not an approved abbreviation.