Every finding on record at Serenity Hills Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #9) 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 #9, Patient remains a full code, no evidence of plan of care documenting patient is a full code.

Upon patient record review 1 of 14 (Patient #10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #10, Aide care plan documented pajamas/gown and dress to be completed by Aide. No evidence these were completed by Aide, as they were not documented as completed.