Every finding on record at Aseracare Hospice-Russellville, L.L.C.

Upon patient record review, 2 of 19 (Patients #2 and 3) did not contain evidence of a current/comprehensive medication profile: Patient # 2: During surveyor attended home visit on 07/16/24 patient's spouse and son were interviewed regarding medications. It was identified that the patient is currently taking the following medications: 1) Pioglitazone: 2) Atenolol: 3) Ozempic: 4) Senna: 5) Zofran: and 6) Novolog. However these medications were not included on the medication profile. Patient #3: During surveyor attended home visit on 07/16/24 patient was interviewed regarding medications. It was identified that the patient is currently taking the following medications: 1) Tamsulosin: 2) Omeprazole: 3) Tums: and 4) Simethicone. However these medications were not included on the medication profile. The medication profile dated 06/05/24 included an entry for, "0.9 normal saline. Keep peripheral patent." This was an incomplete medication entry. The medication profile at time of survey 07/17/24 continued to include an entry for, "0.9 normal saline. Keep peripheral patent." This medication should no longer be on medication profile, as the IV was removed on 06/06/24.

Upon patient record review, 2 of 19 (Patients #2 and 3) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically medications and treatments: Patient #2: During surveyor attended home visit on 07/16/24 the patient's spouse and son were interviewed regarding medications. It was identified that the patient is currently taking the following medications: 1) Pioglitazone: 2) Atenolol: 3) Ozempic: 4) Senna: 5) Zofran: and 6) Novolog. However these medications were not included on the most recent plan of care dated 07/02/24. Patient #3: During surveyor attended home visit on 07/16/24 patient was interviewed regarding medications. It was identified that the patient is currently taking the following medications: 1) Tamsulosin: 2) Omeprazole: 3) Tums: and 4) Simethicone. However these medications were not included on the most recent plan of care dated 07/02/24. The 06/05/24 SOC plan of care included an entry for, "0.9 normal saline. Keep peripheral patent." This is an incomplete medication order. Additionally, the IDG plan of care dated 07/02/24 continued to include an entry for, "0.9 normal saline. Keep peripheral patent." This medication should have no longer been on the plan of care, as the IV had been removed on 06/06/24.

Upon personnel file record review, 1 of 12 (Personnel #8) did not contain evidence of an initial Aide Skills Competency Assessment having been conducted, which included all CMS tasks: Personnel #8: An Aide Skills Competency was conducted between 10/05-10/11/23. However, the following task was not evaluated for: Normal range of motion and positioning. This section of the tool had been left blank by the evaluating RN.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that all entries were clear and complete: Patient #3: SOC RN assessment reflected the presence of a right peripheral IV. During the same visit RN documented, "IV flushed for patency". This documentation is unclear as to location, solution used, amount, and route/method of flush. Additionally, the SN visit report dated 06/06/24 indicated the patient no longer had a peripheral IV. No order was located for the IV discontinuation. Per case manager interview the patient had removed his IV on his own. However there was no nursing documentation within the clinical record reflecting when and how the removal occurred.