Every finding on record at Safe Side Hospice Inc

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 6 (17%) records reviewed revealed the agency did not ensure the wound care provided was included in the patient's plan of care(POC). Clinical Record 4: was reviewed and identified the patient elected hospice care on 1/11/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) on 1/11/2022, documented the patient had a "Stage IV Decubitus ulcer on the Coccyx measuring 1cm x 1cm x 1 cm." The RN documented, "cleansed wound with normal saline, pat dry, packed with 4 x 4, secured with Duoderm." The wound care provided was not included on the plan of care. During a joint record review and interview, the Director of Nurses confirmed the finding and stated, "the daughter is an MD and provides the wound care and the order is not on the plan of care."