Every finding on record at A Kind Heart Palliative Hospice LLC

Upon patient record review, 2 of 6 (Patient #2,4) 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. Patient #2: Medication profile with Sennalax 8.6mg 1 tab po prn- no prn reason listed; Hydralazine 20 mg 2 tabs po q 8 hrs prn- no prn reason listed. Patient #4: Oxygen 2-4 L /m via n/c on POC starting 4/18/22. No evidence of oxygen on the medication profile.

Upon patient record review, 3 of 6 (Patient #2,3,5) 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. Patient #2: Medications on POC include Sennalax 8.6mg 1 tab po prn- no prn reason listed; Hydralazine 20 mg 2 tabs po q 8 hrs prn- no prn reason listed. Patient #3: Risperidone 0.25 mg po daily on medication profile but no evidence on plan of care dated 3/10/22 Patient #5: Medications listed on plan of care dated 4/16/22 with no evidence of PRN reason: Acetaminophen 650 mg rectal q 8-12 hrs prn;Haloperidol 1 mg 1 po q 8-12 hrs prn; Promethazine 25 mg 1 supp rec q 12 hrs prn; Amoxicillin 875-125 mcg 1 po q 12 hrs prn with no evidence of PRN reason.

Upon client record review, 5 of 6 (Patient #1,2,3,4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: POC dated 4/1/22 indicates that CH declined (no order). Chaplain performed visit on 4/4/2022. No evidence of orders for the visit. Patient #2: SW ordered on POC dated 4/30/22 as 1x mo, visit performed 5/3/22 with no evidence of visit in April 2022. Additionally, order on same POC says SCC for spiritual support PRN within certification period. Chaplain made visit on 5/3/22 - there was no indication in the documentation this was a PRN visit. Patient #3: POC dated 3/10/22 SN ordered 1xwk plus 2 prn. Visits made 3/10 and 3/12. 3/12/22 visit did not indicate it was a PRN visit. No order for the additional routine visit. Patient #4: POC dated 4/18/22. SN ordered 1xwk. Two visits made the first week of care on 4/18 and 4/20. There was no documentation to support the second visit was a PRN visit nor an order for the additional visit. Patient #5: POC dated 4/16/22 SN order 1xwk and 2 prn. Two visits made the first week of care on 4/16 and 4/18. There was no documentation to support the second visit was a PRN visit nor an order for the additional visit. No evidence of visits or missed visit documentation for week of 4/24/22 and 5/1/22. Same plan of care Chaplain ordered 1xmo, visit performed 4/19/22. No evidence of visit in May and no missed visit documentation.

Upon patient record review, 5 of 6 (Patient #1,2,3,4,5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1 POC dated 4/1/22 Aide ordered 3xwk, Visits 4/5, 4/7, 4/9. No evidence of a visit the first week of care. Patient #2 POC dated 4/30/22 Aide ordered 3xwk. Visits 5/3, 5/6, 5/8, 5/10, 5/12, 5/14. No evidence of a visit the first week of care. Patient #3 POC dated 3/10/22 Aide order 2xwk. Visits performed 3/11. No evidence of 2nd visit week of 3/10/22. Patient #4 POC dated 4/18/22 aide ordered 2xwk, Visits performed 5/3, 5/5, 5/7, 5/9, 5/11, 5/13, 5/16, 5/18, 5/20. No evidence of a visit in April. Patient #5 POC dated 4/16 Aide ordered 3x wk. Visits 4/18, 4/20, 4/22, 4/26, 4/28, 4/30. No evidence of a visit the first week of care.

Upon client record review, 1 of 3 applicable (Patient #1) did not have evidence that a completed discharge summary was sent to the attending physician.