Every finding on record at Adira Hospice LLC

Upon patient record review, 1 of 5 (Patient #3) 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 Patient 3:On admission, the medical record indicated orders for Hydrocortisone 1% cream apply thin layer BID for itching. Clotrimazole 1% cream apply thin layer BID for rash and Arnicare Gel apply thin layer and massage in TID as needed. There is no evidence on the patient's medication profile of a location for application. The entry for Arnicare gel on the medication profile includes a frequency of PRN and does not include indication for use. The medication profile contains an entry for MiraLAX 17gm daily as needed, there is no evidence of a diluent for administration. Corrected on site.

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) 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:The medical record contained documentation that the patient was using oxygen at 2-4 Liters per minute via nasal cannula as needed. There is no evidence of problem, goals and interventions related to Oxygen therapy and safety on the plan of care. Patient 2:The patients medical record contained an order on 4/26/23 clarifying the patients diet as low sodium diet with semi solid food and aspiration precautions to be observed. There is no evidence of nursing problems goals and interventions related to nutrition/altered diet/ dysphagia on the plan of care. There is documentation on the nursing comprehensive assessment, skilled nurse subsequent visit on 7/17/23 and on the IDG meeting note on 8/16 that the Caregiver continued to have issues with medication management. There is no evidence of nursing problems goals and interventions related to medication management on the plan of care. Patient 3:The medical record contained documentation that the patient was using oxygen at 2-4 Liters per minute via nasal cannula as needed. There is no evidence of problem, goals and interventions related to Oxygen therapy and safety on the plan of care. Patient 5:The record contains nursing documentation of oxygen therapy in use, history of sacral ulcer with current mobility status of bedbound with no bed mobility, pain and comfort issues with multiple locations involved, fall risk and imminent death status. There was no evidence of any nursing problem statements with goals, interventions for management of the current conditions on the plan of care.

Upon patient record review, 2 of 5 (Patient #3,#4) 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: On admission, the medical record indicated orders for Hydrocortisone 1% cream apply thin layer BID for itching. Clotrimazole 1% cream apply thin layer BID for rash and Arnicare Gel apply thin layer and massage in TID as needed. The orders do not include the location for application. The order for Arnicare gel is PRN and does not include indication for use. On admission, the medical record contains an order for MiraLAX 17gm daily as needed, There is no evidence of a diluent for administration. Corrected on site Patient 4: The initial plan of care developed on includes an order for a foley catheter. There is no evidence that the order includes the size of the catheter or the inflation of the balloon as part of the plan of care.

Upon patient record review, 1 of 5 (Patient #4) 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. Patient 4: The medical record contains nursing documentation on admission that the patient is using bed rails and nebulizer equipment and supplies. There is no evidence that bed rails or nebulization equipment and supplies are included on the plan of care.

Upon patient record review 1 of 5 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: The medical record contains an order on 4/26/23 for aide visits 5 times per week. There is no evidence of visits completed the week of 4/26.