Every finding on record at All Heart Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #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. 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 #4: Medication profile listed "hydrocortisone cream to affected area". Instructions were unclear as the site or the indication for the topical ointment.

Upon patient record review, 1 of 14 (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 medications and treatments. Patient #4: Order in medication section on POC listed "hydrocortisone cream to affected area". Instructions were unclear as the site or the indication for the topical ointment.

Upon client record review, 2 of 14 (Patient #13, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13: POC ordered RN 1x per 2weeks. Documentation shows that the RN visited the patient on 5/8, 5/22, 5/27 and 6/7. The visit on 5/27 was an extra visit. No evidence to support the visit was PRN or an order for the extra visit. Patient #14: POC ordered LVN 1x wk. Documentation shows the LVN made 2 visits the week of 4/1 on 4/2 and 4/4. No evidenced to support the visit was PRN or an order for the extra visit.

Upon patient client record review, 1 of 14 (Patient #7) 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 #7: On page 5 of 5 of the Consent paperwork, section with list of items reviewed was left blank.