Every finding on record at Synergy Hospice Services Inc

Upon patient record review 1 of 5 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and 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 1: The clinical record contains an RN comprehensive assessment with no evidence of pain being assessed.

Upon patient record review, 5 of 5 records (Patient #1,#,2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5: The comprehensive assessment does not take into consideration the imminence of death.

Upon patient record review, 1 of 5 records (Patient #1) 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 1: The medication profile contains levetiracetam 100mg, 5ml daily. No evidence of concentration. Corrected on site.

Upon patient record review, 3 of 5 (Patient #1, #4, #5) 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 1: The care plan contains a problem alteration in nutritional status R/T quadriplegic/paralysis with goal of patient not to have weight loss of more than 2 pounds per week. There is no evidence of an intervention in the care plan to weigh patient. Patient 4: The plan of care contains diagnosis of DM Type II and orders for patient taking insulin twice daily. There is no evidence of endocrine being in the care plan. Patient 5: The plan of care contains diagnosis of DM Type II and orders for patient taking insulin twice daily. There is no evidence of endocrine being in the care plan.

Upon patient record review, 1 of 5 records (Patient #1) 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 1: The plan of care contains order for levetiracetam 100mg, 5ml daily. No evidence of concentration. Corrected on site.

Upon patient record review, 1 of 5 records (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: Upon home visit patient had a bed side commode in room. There is no evidence of a bed side commode on the plan of care.

Upon patient client record review, 1 of 5 (Patient #2) did not have evidence that each patient record contains: Patient 2: The clinical record contains a patient notification of hospice non covered items, services and drugs with patient signature though no evidence of a date in the line provided.