Every finding on record at Blue Cross Hospice

Upon patient record review, 2 of 14 (Patient #9, 13) 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 09: The medication profile includes orders on 8/16/23 for "Comfort Kit, as needed, as directed." The profile does not specify the medications included in the kit, medication dosage or instructions for use. Patient 13: The medication profile indicates orders on 3/17/22 for "Comfort Kit, as needed for nausea/vomiting." The profile does not specify the medications included in the kit, medication dosage or instructions for use.

Upon patient record review, 2 of 14 (Patient #9, 13) 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 09: The medication orders on 8/16/23 for "Comfort Kit, as needed, as directed," does not specify the medications included in the kit, dosage of medications, or instructions for use. Patient 13: The medication orders on 3/17/22 for "Comfort Kit, as needed for nausea/vomiting" does not specify the medications included in the kit, medication dosage or instructions for use.

Upon patient record review 1 of 14 (Patient #9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 09: Hospice aide orders were written for 2 times per week starting on 8/29/23. The record indicates that aide services were only provided on 9/1/23 for that week.