Every finding on record at Pure Heart Hospice Inc.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #2 The SN did not have an order for 11/4/21 visit. The visit frequency ordered was SN x1 per week to begin on 11/9/21. Visit frequency not being followed.

Upon patient record review, 1 of 5 (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 equipment and supply needs. Patient #3 This patient had a bedside commode, shower chair. These were not included on the Plan of Care.

Upon patient client record review, 2 of 5 (Patient #2 and #4) 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 Did not have nurse name or signature on initial nursing comprehensive assessment dated 10-28-21 Patient #4 Did not have nurse name or signature on initial nursing comprehensive assessment dated 8-3-21