Every finding on record at Aptiva Hospice and Palliative LLC

Upon patient record review, 6 of 6 records (Patients #1,#2,#3,#4,#5,#6) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5,6: The comprehensive assessment does not contain evidence of consideration of imminence of death.

Upon patient record review, 3 of 6 records (Patient #2,#3,#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. Patient 2: The medication profile contains Lorazepam 1mg Subl Q4 hours prn anxiety with no evidence of concentration. The medication profile contains Morphine Sulfate 0.5mg Subl Q2 hours prn pain, however, the comfort kit orders for the morphine read 20mg/5ml 0.5ml sublingual every 2 hours prn pain. There is no evidence of a concentration for the morphine and the dose is incorrect. Atropine 1% opth subl Q2 hours prn secretions. The is no evidence of a dose. Corrected on site. Patient 3: The medication profile contains Lisinopril 5mg PO TID. Finding at home visit the medication bottle reads Lisinopril 5mg daily. The nurse confirmed the dose to be Lisinopril 5mg daily. Corrected on site. Patient 6: The medication profile contains an order for Miralax 17gr po daily with no evidence of diluent. Corrected on site.

Upon patient record review, 4 of 6 records (Patient #2,#3,#5,#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 2: The plan of care contains Lorazepam 1mg Subl Q4 hours prn anxiety, however, no evidence of concentration. The plan of care contains Morphine Sulfate 0.5mg Subl Q2 hours prn pain, however, the comfort kit orders for the morphine reads 20mg/5ml 0.5ml sublingual every 2 hours prn pain. There is no evidence of a concentration for the morphine and the dose is incorrect. The plan of care contains documentation of Atropine 1% opth subl Q2 hours prn secretions. The is no evidence of a dose. Corrected on site. Patient 3: The plan of care contains Lisinopril 5mg PO TID. Finding at home visit, the medication bottle reads Lisinopril 5mg daily. The nurse confirmed the dose to be Lisinopril 5mg daily. Corrected on site. Patient 5: The Recert plan of care, in the medications list, the SN writes "See med list". There is no evidence of a signed order by the physician for the medications for this certification period. Corrected on site. Patient 6: The plan of care contains an order for Miralax 17gm po daily, there is no evidence of diluent. Corrected on site.

Upon patient record review, 2 of 6 records (Patient #1,#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 equipment and supply needs. Patient 1: SN visit on 10-6-21 has assistive devices checked and SN writes in Hoyer lift. There is no evidence of a Hoyer lift on the POC. Corrected on site. Patient 4: Upon home visit patient is noted to have an air mattress. There is no evidence of an air mattress on POC. Corrected on site.

Upon client record review, 2 of 6 records (Patient #2,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The plan of care contains an order for SN 1 time per week. There is evidence of the SN visiting the patient twice the week of 11-7-21-11-13-22 on 11-7-21 and 11-12-21. There is not evidence that either visit is prn. There is evidence of the SN visiting the patient twice the week of 11-21-21--11-27-21 visits performed on 11-21-21 and 11-25-21 with no evidence of either visit being prn. Patient 5: The plan of care contains an order for SN 1 time per week. There is evidence the SN made 2 visits the week of April 10-16. The visits were made 4-10-22 and 4-16-22 with no evidence of either visit being prn.

Upon patient record review 1 of 5 applicable records (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The plan of care contains an order for an aide 3 times per week. Patient was admitted on 11-4-21 and only one visit was made the first week of service on 11.6.21. There was no missed visit documentation. The week of 11-7-21--11-13-21, the aide made visits on 11-7-21,11-8-21,11-10-21,11-12-21 with no evidence of an order for increased visits.

Upon patient client record review, 2 of 6 records (Patient #3,#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 3: The medical record contains aide progress notes on 4-4-22,4-7-22,3-23-22,3-21-22 with no patient name and no aide signature. Corrected on site. Patient 5: The medical record contains aide progress notes on 3-28-22, 3-30-22, 4-1-22, 4-5-22,4-7-22,4-9-22,4-12-22,4-14-22,4-16-22 with no patient name and no aide signature. Corrected on site.