Every finding on record at Serafim Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #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 4:The nurse documentation on admission with port a cath to right chest noted. There is no evidence of problems, goals and interventions related to port a cath on the plan of care.