Every finding on record at Care Me Hospice Inc.

Upon patient record review, 2 of 14 (Patient #4,#6) 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: The patient's medication administration record includes multiple entries of Eliquis 2.5 mg by mouth BID for anticoagulation. On admission, the patient's medication administration record with entry of oxygen profiled to be delivered at 2-4 liters per minute. There was no evidence that a route for delivery of oxygen is included on the medication profile. Corrected on site. Patient 6: The patient's medication administration record includes entries for mupirocin ointment, nystatin powder and lortisone cream. There is no evidence that a location for application is included on the medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #3) 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 3: The patient's medical record contains nursing documentation that nursing visits from 6/28/23 through 7/25/23 were completed by licensed vocational nurses. There is no evidence that a registered nurse comprehensive assessment was completed within 15 days during that period.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: The patients medical record contains documentation upon admission, and ongoing, of a stage 4 pressure ulcer present on coccyx. There was documentation of wound care being provided. There is no evidence that wound assessments and measurements were completed and documented every 14 days as required by agency policy.

Upon patient record review, 3 of 14 (Patient #4.#6,#12) 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 4: The patients medical record contains nursing documentation upon admission that patient was currently using Eliquis as an anticoagulant and was a high risk for falls. There is no evidence of problems with goals and interventions to manage anticoagulation therapy and safety. Corrected on site. Patient 6: The patient's medical record contains nursing documentation on admission that pain is an active problem and that the patient was utilizing oxygen at 2-5 liters per minute. There is no evidence of problems, goals and interventions related to pain or oxygen therapy included in the plan of care. Corrected on site. Patient 12: The patient's medical record contains nursing documentation on 4/7/23 that the patient is scheduled to be discharged based on extended prognosis. There is no evidence that the plan of care was updated to reflect problems, goals and interventions related to the pending discharge. Corrected on site

Upon patient record review, 3 of 14 (Patient #4,#5,#6) 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 4: On admission, the patient's plan of care included an order for oxygen at 2-4 liters per minute as needed. There is no evidence that the order includes the delivery route for the oxygen. Corrected on site. Patient 5: On admission, the patient's plan of care included a wound care order for sacral pressure ulcer. There is no evidence that the wound care order includes a bordered dressing, which is what the agency was using. Corrected on site. Patient 6: On admission the patient's plan of care included orders for mupirocin ointment, nystatin powder and lortisone cream. There is no evidence that a location for application is included on the order. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4: The patient's medical record contains nursing documentation that the patient is at high risk for falls and is on an anticoagulant therapy. The task of showering patient is assigned every visit and there is no evidence of fall precautions or bleeding precautions included on the aide plan of care.

Upon patient record review 2 of 14 (Patient #5,#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 5: The aide plan of care developed on 5/30/23 included the task of drain catheter bag, measure urine and document amount every visit. There is no evidence in aide visit documentation since initiation of plan that the task was completed. Patient 9: The aide plan of care developed on admission included the task of document date of last bowel movement every visit. There is no evidence that the task was completed and documented during visits on 6/24/23, 7/6/23, 7/17/23.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 3: The patient's medical record contains documentation that the aide provided care per aide plan of care beginning 6/28/23. There is no evidence in the medical record that the registered nurse made an on site visit no less frequently than every 14 days.