Every finding on record at Astral Palliative Hospice Care Inc

Upon patient record review, 1 of 5 (Patient #1) 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 #1: This patent had a nebulizer inhalation solution medication ordered for Albuterol/Ipratropium Bromide (Duo-Neb). The medication profile listed Albuterol only and PO use, not inhalation route.

Upon patient record review, 1 of 5 (Patient #1) 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 #1: This patent had a nebulizer inhalation solution medication ordered for Albuterol/Ipratropium Bromide (Duo-Neb). The Plan of Care listed the medication route as PO use, not inhalation route.

Upon patient record review, 1 of 5 (Patient #1) 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: Had a nebulizer machine. This item was not included on Plan of Care.

Upon patient record review, 1 of 5 (Patient #2) 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. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #2: The CTI did not have correct benefit period dates for Benefit Period #1. The CTI read- 6/30/24-9/28/24 (91 days). The benefit should have read 6/30/24-9/27/24 (90 days).

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: Did not have BFCC-QIO Contact information (name, phone) filled in space provided on form.