Every finding on record at Vbm Hospice Inc.

Upon patient record review, 2 of 6 (Patient #1, 3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, 3 : Plan of care includes MSW and SC frequencies of 1 prn, with no routine frequency.

Upon patient record review, 1 of 6 (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 medications and treatments. Patient #3. "Secondary DX of Long Term (current) Use of Insulin" included initial POC. However, there is no current dose for insulin in MD Orders or Medication profile. During home visit, patient reports that he is actually taking insulin daily. There is no insulin listed on medication profile.

Upon client record review, 1of 6 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 POC includes order for regular diet. 6/12 and 7/3/23 SN notes refer to NAS Heart Healthy Diet. Also, during patient home visit and interview, patient refers to SC by name and states SC visits 1-2x/month. He enjoys visits. RN verifies patient receiving SC service. The order frequency for SC is prn x 1. There are no visit notes filed in clinical record.

Upon patient client record review, 1 of 6 (Patient #4) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4 5/15/23 Note "... standing BP 160/108. Patient has co of temporal headache. Denies vision changes or dizziness/vertigo. MD notified of elevated BP and headache and lower leg edema. See orders." This information was documented exactly the same on 6/26/23, although no new order.