Every finding on record at 5 Star Hospice

Upon patient record review, 3 of 14 (Patient #3,4,5) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring #3-Medication profile dated 02/25/25 includes Diclofenac Sodium 1% topical gel, apply topically to affected area twice daily. The order does not include an amount or a location. #4-Medication profile dated 01/10/25 includes Triamcinolone Acetonide 0.1% apply topically to affected area twice daily. The order does not include an amount or a location. #5-Medication profile dated 11/08/24 includes Diclofenac Sodium 3% topical gel 2 grams topically to affected area twice daily as needed. The order does not include a location or an indicator.

Upon patient record review, 2 of 14 (Patient #3,7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. #3-Patient reported on 03/03/25 that pain was not managed on current regimen and Tramadol 50 mg daily as needed was ordered. There is no evidence in the chart that follow-up took place to determine if the new medication was effective. #7-Patient reported on admission that pain was a 5/10 and controlled "fairly well." There is no evidence that the nurse followed up to determine if the patient was satisfied with the current regimen or if the patient felt a 5/10 was an acceptable pain level.

Upon patient record review, 3 of 14 (Patient #3,4,5) 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. #3-Plan of care dated 02/25/25 includes Diclofenac Sodium 1% topical gel, apply topically to affected area twice daily. The order does not include an amount or a location. #4-Plan of care dated 01/10/25 includes Triamcinolone Acetonide 0.1% apply topically to affected area twice daily. The order does not include an amount or a location. #5-Plan of care dated 11/08/24 includes Diclofenac Sodium 3% topical gel 2 grams topically to affected area twice daily as needed. The order does not include a location or an indicator.

Upon patient record review, 11 of 14 (Patient #1,2,4,5,6,7,8,9,10,13) 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. #1-Plan of care dated 02/18/25 does not include DME and patient requires a walker. #2-Plan of care dated 02/10/25 does not include DME and patient requires walker and shower chair. #4-Plan of care dated 01/10/25 does not include DME and patient requires a walker. #5-Plan of care dated 11/08/24 does not include DME and patient requires a walker, shower chair, nebulizer, oxygen concentrator, portable E tank and a bedside commode. #6-Plan of care dated 02/19/25 does not include DME and patient requires a cane, shower chair and walker. #7-Plan of care dated 02/08/25 does not include DME and patient requires a cane, walker and shower chair. #8-Plan of care dated 02/08/25 does not include DME and patient requires a walker and shower chair. #9-Plan of care dated 01/26/25 does not include DME and patient requires a cane, walker and geri-chair. #10-Plan of care dated 01/25/25 does not include DME and patient requires a cane. #13-Plan of care dated 02/04/25 does not include DME and patient requires a cane, walker and shower chair.

Upon patient record review, 8 of 14 (Patient #1,4,5,6,7,8,9,10,12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 #1,4,5,6,7,8,9,10,12-Signed Patient Notification of Hospice Non-Covered Items addendum is incomplete - does not contain the diagnoses unrelated to the terminal illness and related conditions, or a written clinical explanation as to why items are not covered.

Upon patient client record review, 1 of 14 (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. #4-Assessment data on start of care dated 01/10/25 is conflicting. The patient is scored as a 6E on the FAST and a 7A on the Alzheimer's LCD

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #2 has diagnosis of Alzheimer and signed her own consents.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #2 has diagnosis of Alzheimer and initial assessment documented confusion. Patient signed her own consent. Agency confirmed that the patient's daughter and caregiver were present during hospice admission.

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 #1 medication profile states Advil 200mg tablet, 2 tablets every 6 hours PRN, class: non steroid anti inflammatory drugs/NSAID. No reason for PRN medication was documented.