Every finding on record at Angel Loving Care Hospice Inc.

Upon patient record review, 2 of 5 records (Patients #3.#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. Patient 3: The medication profile contained albuterol nebulizer and Breo Ellipta inhaler with routes of by mouth and an albuterol inhaler with no route identified. Corrected on site. Patient 4: The medication profile contained a Spiriva inhaler with no route identified.

Upon patient record review, 1 of 5 records (Patient #3) 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 3: The medical record contains nursing documentation upon admission identifying patient use of a Hoyer lift and walker. There is no evidence of the lift and walker included in the plan of care. Corrected on site.

Upon patient record review, 3 of 5 (Patient #1,2,5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patients 1: The medical record contain the Certification of Terminal Illness document with primary hospice diagnosis identified as End Stage Cardiac Disease at the top of the form and physician narrative determines primary diagnoses as Senile Degeneration of the Brain. Documentation is incongruent. Patient 2: The medical record contain the Certification of Terminal Illness document with primary hospice diagnosis identified as End Stage Cardiac Disease at the top of the form and physician narrative determines primary diagnoses as Senile Degeneration of the Brain. Documentation is incongruent. Patient 5: The medical record contain the Certification of Terminal Illness document with primary hospice diagnosis identified as End Stage Cardiac Disease at the top of the form and physician narrative determines primary diagnoses as Senile Degeneration of the Brain. Documentation is incongruent.

Upon patient client record review, 1 of 5 records (Patients #5) 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. Patient 5: The medical record contains the initial physician orders/plan of care with conflicting information. Aide frequency is listed as twice weekly, however, the plan of care also states aide services were refused. Additionally, the comprehensive nursing assessment form completed upon admission states date of visit 1/2/22 on page 1 and signature date is 12-26-21. Admission comprehensive assessment was completed 12-26-21.