Every finding on record at Best Care Hospice LLC

Upon patient record review, 2 of 19 (Patient #2,#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. 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 2:The medication profile includes duplicate entries for oxygen. One of the oxygen entries includes an oxygen range from 2-5 liters per minute with no evidence of instructions for titration of oxygen. Patient 4:The medication profile includes duplicate entries for oxygen. The entry on the medication profile for lorazepam includes a range for the dosage and no instructions on titration.

Upon patient record review, 3 of 19 (Patient #1,#3,#4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1:The medical record contains documentation on admission of Xarelto used for anticoagulation therapy and the presence of a colostomy to the right lower abdomen. There is no evidence that the care plan includes problem, goals and interventions for the potential for bleeding or the management of the colostomy. Patient 3:The patient is admitted to service with the primary diagnosis of cardiac disease with symptom management needed for edema. There is no evidence that the plan of care includes problems, goals and interventions for management and symptom control for cardiac disease. Patient 4:The medical record contains nursing documentation that the patient requires a foley catheter, is at risk for aspiration due to dysphagia and uses oxygen for shortness of breath. There is no evidence that the plan of care includes problems, goals and interventions for management of the foley catheter, potential for aspiration or the use and safety of oxygen.

Upon patient record review, 2 of 19 (Patient #6, #7) 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 6:The medical record contains nursing documentation that the patient uses CPAP at night. There is no evidence that the plan of care includes an order for CPAP. Patient 7:The plan of care includes an order for wound care to the Pleurx drain site. There is no evidence that the order includes the type of dressing used and who is to perform care.

Upon patient record review, 1 of 19 (Patient # 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 4:The medical record includes nursing documentation that the patient is in a skilled facility and requires a hospital bed and side rails. There is no evidence that the plan of care includes a hospital bed and side rails.

Upon client record review, 2 of 5 (Patient #1,2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1 - The record indicated a plan of care review at an IDG meeting was completed on 10/4/21 but the next one was not completed till 10/21/21 which is over the 15 days requirement. Patient #2 - The record indicated a plan of care review at an IDG meeting was completed on 10/5/21 and the next one was not completed till 10/21/21 which is over the 15 day requirement.