Every finding on record at Pro-Med Hospice Inc

Upon patient record review, 2 of 5 (Patient #2, 4) 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 and #4- The medical record contained information that the patient was on aspirin. The plan of care did not include goals and interventions related to the patient's risk for bleeding.

Upon patient record review, 1 of 5 (Patient #2) 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- The plan of care indicated that the patient lived in a private residence, however upon home visit it was determined that the patient resided in a board and care facility.