Every finding on record at South Coast Hospice Services Inc

Upon patient record review 1 of 5 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5 There was no evidence of a spiritual assessment completed.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 4: The medication profile contained instructions Miralax with no diluent. Corrected on site.

Upon patient record review, 1 of 5 records (Patient 4) 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 medications and treatments. Patient 4: The Physician's order for Miralax did not contain instructions for the diluent. Corrected on site.

Upon patient client record review, 5 of 5 records (Patient #1, #2, #3, #4 and #5) 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. Patient 1: The nursing documentation identified continuous oxygen use with each assessment starting 1/10/22. After leadership investigation it was identified patient was not on oxygen. Corrected on site with coordination note explaining data entry errors within the nursing documentation. The medical record contained consents and election of benefit forms signed by patient representative. There was no evidence of explanation of relationship to patient on forms to indicate legal authority. Coordination notes provided for explanation of relationship during survey. Patient 2: The medical record contained consents and election of benefit forms signed by patient representative. There was no evidence of explanation of relationship to patient on forms to indicate legal authority. Coordination notes provided for explanation of relationship during survey. Patient 3: The medical record contained an authorization form that was blackened and illegible in sections. Patient 4: The medical record contained consents and election of benefit forms signed by patient representative. There was no evidence of explanation of relationship to patient on forms to indicate legal authority. Coordination notes provided for explanation of relationship during survey. Patient 5: The medical record contained consents and election of benefit forms signed by patient representative. There was no evidence of explanation of relationship to patient on forms to indicate legal authority. Coordination notes provided for explanation of relationship during survey.