Every finding on record at Your Choice Palliative Care, Inc

Upon patient record review, 4 of 14 (Patient #5,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients 5, 7, 8, & 9: MSW completed initial assessments via telephone. There is no evidence of the order contained in the patient plan of care.

Upon patient client record review, 1 of 14 (Patient #3) 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 3: 6/28/24 nursing visit documentation reflects, "Wound care provided per plan of care" with no further clarification of the actual wound care provided.