Every finding on record at Blue Horizon Hospice of Texas, LLC

Upon patient record review, 1 of 6 (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:The medication profile includes an entry for oxygen 2-4 liters per minute as needed for shortness of breath. There is no evidence that the entry includes instructions for titration of oxygen.

Upon patient record review, 1 of 6 (Patient #2) 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 2:The medical record includes documentation that the patient is at risk for falls. There is no evidence that the plan of care includes active problems, goals and interventions for the the risk for falls.

Upon patient record review, 1 of 6 (Patient #2) 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 2:The medical record includes documentation on admission that the patient requires a rollator for ambulation. There is no evidence that a rollator is included on the plan of care.

Upon patient client record review, 1 of 6 (Patient #3) 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 medical record contains nursing documentation on 7/5/24 that the patient has a Gastrostomy tube for nutrition. Upon interview with the administrator and visit to the patient, the patient does not have a gastrostomy tube.