Every finding on record at Bona Fide Hospice Inc

Upon patient record review, 1 of 14 (Patient #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 4: During the home visit, the owner assisted in completing a medication reconciliation and stated the instructions for the vitamin D is to be administered weekly. The hospice medication profile contained instructions for daily administration. The owner also showed mometasone furoate steroidal cream as currently being used as needed by the patient. The steroidal cream was not listed on the medication profile.

Upon patient record review, 4 of 14 (Patients #1,#3,#7,#10) 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 1,3,10: The medical records contained nursing documentation upon admission identifying patients were a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment included in the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient issues with dyspnea and high risk for skin impairment. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and risk for skin impairment included in the plan of care.

Upon patient record review, 8 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#10) 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: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a shower chair and commode. There was no evidence of orders for the DME included in the plan of care. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed. There was no evidence of an order for the bed included in the plan of care. Patient 4: During the home visit, the owner stated the patient utilizes a cane intermittently for ambulation. There was no evidence of an order for the cane included in the plan of care. Patient 5: During the home visit, the patient stated they utilize a walker and wheelchair for ambulation, both of which were present in the room. There was no evidence of orders for the DME included in the plan of care. Patient 6: During the home visit, the owner stated the patient utilizes a cane intermittently for ambulation. There was no evidence of an order for the cane included in the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair and nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of an over bed table and shower chair. There was no evidence of orders for the DME included in the plan of care.

Upon client record review, 2 of 14 (Patients #9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients 9,10: The medical records contained an order for LVN visits weekly and RN visits once every two weeks. The LVN and RN were each visiting once alternating every other week, not meeting LVN frequency for once weekly.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 8: The bereavement care plan did not identify the tasks and frequencies of tasks planned for completion. The care plan only included for a sympathy card and one month letter to be sent, however there was documentation that letters were also sent at 3, 6, 9, 12, and 13 months.

Upon patient client record review, 1 of 14 (Patient #8) 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 8: The SW initial assessment was time stamped for 10 pm occurring after patient already expired at 6 pm. Documentation stated patient was communicative during the visit.