Every finding on record at Asclepius Hospice Care, LLC

Upon observation, there was no evidence of a contract/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Patients' physicians • Other hospices

Upon patient record review, 1 of 5 (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 and includes duplicate drug therapy Albuterol for the patient was listed with the wrong route of administration as oral, and Lisinopril 10 mg was listed twice.

Upon patient record review, 5 of 5 (Patient #1,2,3,4 & 5) plan of care did not include all that were necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. The following medications identified as active during the comprehensive assessment and medication profile were not included in the plan of care. Patient #1 had PERMETHRIN 50MG, TRAZADONE 100MG, MELATONIN 5MG, PRIMIDONE 250MG, QUETAPINE FUMARATE 150MG Patient #2 had OLANZAPINE 5MG, PROPANOLOL 10MG, ASPIRIN 81MG, TRIHEXYPHENIDYL HYDROCHLORIDE 5MG,ZIPRASIDONE 80MG Patient #3 had ACETAMINOPHEN 325MG, ACETAMINOPHEN 650MG, BISACODYL 10MG, CODEINE GUAIFENESSIN 10-100MG, FENTANYL PATCH 75MCG, LORAZEPAM 2MG, MORPHINE SULAFATE 20MG/ML, QUETAPINE FUMARATE 50MG Patient #4 had ALBUTEROL 90MCG, DEBROX 0.065MG, LISINOPRIL 10MG, SERTRALINE 50MG Patient #5 had RISPERDAL 1MG

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient's comprehensive assessment included DME's and was observed during home visit to have the Hospital Bed, Oxygen Concentrator, Overbed Table which were not listed in the Plan of care.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the required competency assessment was performed by the aide with a patient or a pseudo patient. Aide services have been provided.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence of a job description for the alternate administrator in the personnel record.

Upon personnel record review, 2 of 13 (Personnel #9 & 10) did not have evidence in personnel files that a skills competency assessment, specific to their discipline had been conducted initially during orientation.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 2 of 13 (Personnel #7,8) did not have evidence of the Fingerprint clearance card for direct care personnel in accordance with the state of Arizona requirements.