Every finding on record at Best Quality Hospice and Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #8) 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#8: The medication profile contained diclofenac sodium 1% to be applied topically once a day. There is no evidence of a specified area of application. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#4: The record indicates RN visit was made on 2/25/25. The next documented RN visit was made on 3/13. There is no evidence of an RN assessment before day 16.

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#5) 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 record indicates patient is ordered oxygen, takes Eliquis 5mg twice a day, and is at high risk skin breakdown. There is no evidence of problems with goals or interventions related to oxygen safety, bleeding precautions, and education on skin precautions. Corrected on site. Patient#2: Documentation from nurse admit note and IDG on 2/21/25 indicates patient requires education on prevention of skin breakdown. Additionally, patient takes Plavix daily. There is no evidence of problems with goals and interventions for skin precautions or for bleeding precautions on plan of care. Corrected on site. Patient#3: The record indicates patient requires oxygen and is a fall risk per documentation by nurse of patient having recent fall with bruising prior to admit. There is no evidence of problems with goals or interventions related to oxygen safety or fall prevention. Corrected on site. Patient#5: The record contains a physician order to instruct patient/caregiver on foot care. There is no evidence of goals or interventions related to foot care education. Corrected on site.

Upon patient record review, 1 of 14 (Patient #8) 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#8: The medical record contained an order for diclofenac sodium 1% apply topically once a day. There is no evidence of a specified area of application. Corrected on site.

Upon patient record review, 2 of 14 (Patient #4,#5) 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 record indicates patient requires use of shower chair and bars per nurse documentation. There is no evidence of these items on plan of care. Corrected on site. Patient#5: The record indicates patient requires use of oxygen per nurse documentation. There is no evidence of oxygen concentrator or tanks on plan of care. Corrected on site.

Upon client record review, 4 of 14 (Patient #4,#5,#7,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#4: The plan of care indicates nurse frequency is 1 time per week. However, there are 2 nurse visits documented the weeks of 2/13/25 and 2/23. Additionally, there are 2 nurse visits documented on 3/13 and on 3/17. There is no evidence of these visits being PRN. Corrected on site. Patient#5: The plan of care indicates nurse frequency is 1 time per week. There is evidence of 2 routine nurse visits being made on 3/14/25 and on 3/28. Corrected on site. Patient#7: The plan of care indicates nurse frequency is 1 time per week. There is evidence of 2 routine nurse visits being made 3/9/25 and on 3/23. Corrected on site. Patient#9: The plan of care indicates nurse frequency is 1 time per week. However, there are 2 nurse visits documented the weeks of 2/17/25, 3/3, and 3/17. Corrected on site.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: The record review indicated on IDG 3/21/25 and 4/7 documentation states under bereavement coordinator that urine analysis results received, Dr Barrientos notified, and received order for cipro 500mg BID for 10 days. However, there was no evidence of an order or any other documentation regarding urine analysis or UTI.

Upon patient client record review, 2 of 14 (Patient #3,#6) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#3: The record indicates neutropenic precautions are indicated on aide plan of care, but not found anywhere else in patient record. Per discussion with Administrator it was determined that this was a documentation error. Patient#6: The record review indicated on nurse admit documentation patient requires a regular low fat no added sodium diet. The MD order states mechanical soft diet.