Every finding on record at Warmful Love Hospice Inc

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,6) 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 #1,2,3,4,5,6, No evidence of funeral home documented on initial MSW assessment and no evidence of plan for funeral arrangements documented in care plan for patient. Patient #6, Code status states undecided. No evidence of patient code status.

Upon patient record review, 3 of 14 (Patient #1,3,4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1, For benefit period 9/22/24, no evidence of brief narrative explanation of the clinical findings supporting life expectancy of 6 months or less. Patient #3, For benefit period 8/26/24, no evidence of brief narrative explanation of the clinical findings supporting life expectancy of 6 months or less. Patient #4, For benefit period 9/28/24, no evidence of brief narrative explanation of the clinical findings supporting life expectancy of 6 months or less.

Upon patient client record review, 1 of 5 (Patient #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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5 - The record indicated in the initial visit nurse's note, the initial POC/IDG Review and on the CTI all dated 8/6/21 that the patient's primary terminal diagnosis was Parkinson's Disease. The physician in the CTI narrative note dated 8/6/21 said "terminal illness such as Heart Disease." There was no evidence in the CTI physician narrative note that the patient's terminal diagnosis was Parkinson's Disease.