Every finding on record at Adjustable Care Life Inc

Upon patient record review, 1 of 14 (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: The plan of care includes an order for oxygen 2 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence of an entry for oxygen on the medication profile.

Upon patient record review, 2 of 14 (Patient #4,#5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 4:The patient was admitted to hospice on 1/16/24. There is no evidence that a bereavement risk assessment was completed prior to 2/18/24. Patient 5:The patient was admitted to hospice on 1/5/24. There is no evidence that a bereavement risk assessment was completed prior to 2/16/24.

Upon patient record review, 3 of 14 (Patient #3,#4,#7) 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 3:The medical record contains an order for oxygen 2 liters per minute via nasal cannula PRN for shortness of breath. There is no evidence of problems, goals and interventions for the use and safety of oxygen on the plan of care. Patient 4:The medical record contains nursing documentation on admission that the patient is at risk for seizures. There is no evidence of problems, goals and interventions related to the risk for seizures on the plan of care. Patient 7:The medical record contains nursing documentation on admission that the patient required an indwelling foley catheter. There is no evidence of problem, goals and interventions related to the management of a foley catheter on the plan of care.

Upon patient record review, 1 of 14 (Patient #7) 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 7:The medical record includes an order entered on 9/22/23 of Nystatin Powder thin layer to rash. There is no evidence in the order of the location for administration of the Nystatin powder.

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient 1: The medical record includes SN documentation that the patient equipment needs includes a walker and shower chair. There is no evidence that a walker and shower chair are included on the plan of care.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4:The medical record includes SN documentation of foley catheter insertion on 4/7/24. There is no evidence that the plan of care included an order for foley catheter placement.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4:The aide plan of care includes the task of dressing patient in PJ/Gown. There is no evidence of a frequency associated with the provision of the care.