Every finding on record at Unsurpassed Hospice Inc

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: POC dated 3/3/25 orders that the nurse assess for trophic ulcers. There is no documentation that there was an assessment of the legs/feet for ulcers.

Upon patient record review, 1 of 5 (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 Record #1: Initial orders 12/29 include order to call (MD) if PO2 <88. There is no order identified for Oxygen administration. There is a 12/29 9:30 am DME order for Oxygen Concentrator. The Integrated Plan of Care, Problem #7 Altered Discomfort: Dyspnea, SOB lists intervention to Instruct in safe Oxygen and equipment use. There are references to Oxygen therapy, but there is no order for specific administration of oxygen.

Upon patient client record review, 1 of 5 (Patient #1) 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 Record #1: Initial Med orders include order for Digoxin 0.125 mg 1 tab by mouth daily. There is an illegible black-out of words adjacent to the med order. On the med profile, the same is true. Digoxin 0.125 1 tab by mouth daily is listed and directly under, is illegible black-out of words.