Every finding on record at Ametrine Hospice

Upon patient record review, 3 of 14 (Patient #5, 8, 12) 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 #5 - Medication profile contains Catapres 1mg 1 tab by mouth as needed without evidence of indicator for use. Patient #8 - Medication profile contains Narcan nasal spray "use as directed as needed" without evidence of indicator for use, dosing, and directions. Patient #12 - Medication profile contains Narcan nasal spray "use as directed as needed" without evidence of indicator for use, dosing, and directions.

Upon patient record review, 1 of 14 (Patient #9) 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 #9 - Agency unable to provide initial bereavement assessment.

Upon patient record review, 3 of 14 (Patient #8, 10, 11) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #8 - POC dated 10/23/23 RN completed comprehensive assessment on 10/23/23 and next RN visit 11/06/23 no comprehensive assessment completed. Patient #10 - POC dated 10/19/23 RN completed comprehensive assessment on 10/19/23 and next RN visit 11/03/23 no comprehensive assessment completed. Patient #11 - POC dated 10/18/23 RN completed comprehensive assessment on 10/18/23 and next RN visit 11/01/23 no comprehensive assessment completed.

Upon patient record review, 4 of 14 (Patient #8, 9, 10, 11) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #8 - POC dated 10/23/23 - SC and MSW visit frequency 1 visit then PRN. Patient #9 - POC dated 09/28/23 - SC and MSW visit frequency PRN. Patient #10 - POC dated 10/19/23 - SC and MSW visit frequency 1 visit then PRN. Patient #11 - POC dated 10/18/23 - SC and MSW visit frequency 1 visit then PRN.

Upon patient record review, 3 of 14 (Patient #5, 8, 12) 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 #5 - Order for Catapres 1mg 1 tab by mouth as needed does not contain evidence of indicator for use. Patient #8 - Order for Narcan nasal spray "use as directed as needed" does not contain evidence of indicator for use, dosing, and directions. Patient #12 - Order for Narcan nasal spray "use as directed as needed" does not contain evidence of indicator for use, dosing, and directions.

Upon patient record review, 4 of 14 (Patient #5, 9, 13,14) 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 #5 - POC dated 10/22/23 did not include walker or cane. Patient #9- POC dated 09/28/23 did not include oxygen equipment. Patient #13 - POC dated 10/22/23 did not include walker or wheelchair. Patient #14 - POC dated 08/25/23 did not include oxygen equipment.

Upon client record review, 3 of 14 (Patient #5, 6, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5 - POC 10/22/23 SN visit frequency 1 x week 2 visit made week 1. Patient #6 - POC 10/10/23 SN visit frequency 1 x week 2 visit made week 3. Patient #14 - POC dated 08/25/23 SC visit frequency x1 visit however, visits were made on 08/28/23, 09/28/23, 10/23/23.

Upon patient record review 4 of 14 (Patient #8, 10, 11, 12) 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 #8 - POC dated 10/23/23/Aide visit frequency 2xweek - only 1 visit made week 1. Patient #10 - POC dated 10/19/23/Aide visit frequency 2xweek - only 1 visit made week 1. Patient #11 - POC dated 10/18/23/Aide visit frequency 2xweek - only 1 visit made week 1. Patient #12 - POC dated 10/16/23/Aide visit frequency 2xweek - only 1 visit made week 1.