Every finding on record at All State Hospice Care, Inc.

Upon patient record review, 1 of 14 (Patient #6) 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 6:The medical record includes nursing documentation on admission and subsequent visits that the patient has chronic back pain and uses Tylenol 325mg 2 tabs every 6 hours as needed for pain. There is no evidence that the medication profile includes an entry for Tylenol.

Upon patient record review, 1 of 14 (Patient #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 7:The medical record includes nursing documentation that the patient is at high risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for the management of the fall risk.

Upon patient record review, 1 of 14 (Patient #6) 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 6:The medical record includes nursing documentation on admission and subsequent visits that the patient has chronic back pain and uses Tylenol 325mg 2 tabs every 6 hours as needed for pain. There is no evidence that the plan of care includes an order for Tylenol.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization did not conduct and document a patient-specific comprehensive assessment that identifies the need for hospice care and services, including anticipated bereavement needs and survivor risk factors before the death. In review of the record for HV#1 and HV#2, an initial bereavement assessment was not completed and documented as part of the comprehensive assessment/admission process per organizational policy. This was reveiwed and confirmed with the Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not assure the plan of care included the scope and frequency of the services necessary to meet the patient's and family's needs. In review of the record for HV#3, it was noted that although all members of the interdisciplinary team (IDT) signed the plan of care at the initial IDT meeting, the section for MSW and Spiritual Care reports/plans/updates was blank. There was no information included/documented by the MSW or Spiritual Care Counselor regarding the planned scope and frequency of services to meet the patient's/family's needs related to grief associated with the recent death of the patient's son. This was reveiwed and confirmed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not plan the patient's care and services needed for the palliation and management of the terminal illness and related conditions, including all medications/treatments necessary to meet the patient's needs. In HV#1, the caregiver indicated the patient took Acetaminophen as needed for mild pain. This prn medication was not included on the patient's plan of care/medication profile. Per the caregiver during HV#2, the patient took Ibuprofen or Advil as needed for back pain. There were no prn analgesics noted in the patient's plan of care/medication list. This was reveiwed and confirmed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not reduce the risk of infection associated with medical equipment, devices, and supplies. In HV#1 and HV#2, the skilled nurse did not follow organizational policy and manufacturer's recommendations when cleaning and performing disinfection of medical supplies and devices. The LVN did not allow for the product manufacturer's recommended two (2) minute product contact time and air drying when cleaning care equipment (BP monitor, pulse oximeter, stethoscope) before placing the wet items back into the field bag. It was also noted the LVN used a different cleaning product than those outlined in the organization's policy for cleaning care equipment (alcohol or soap/water). This was reveiwed and confirmed with the Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not maintain complete, accurate, and accessible patient records. In RR#2, it was noted in the initial assessment the patient had a stage 2 pressure wound. Wound documentation was incomplete/inaccurate for the pressure wound, with no location, measurements, or assessment documented in the hospice record. The organization recently transitioned from an electronic hospice record to paper, and was unable to retrieve/produce the wound assessment document. This was reveiwed and confirmed with the Administrator.