Every finding on record at Care View Hospice Care

Upon patient record review and home visit, 2 of 5 records (Patient #1,3) 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 contained Diclofenac 1%, 2 grams, 2 times/day pain. There was not evidence of a specific location. Patient #3: The medications on the medication profile were consistent with the medications on the plan of care and what the patient/caregiver states they are taking. While reconciling the medications against the medication profile, Amiodarone, Amlodipine, ASA, Hydralazine and Metoprolol were on the medication profile but not identified in the home.

Upon patient record review, 1 of 5 records (Patient #1) 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 #1: The record contained an order for Diclofenac 1%, 2 grams, 2 times/day pain. There was not evidence of a specific location.

Upon patient client record review, 1 of 5 records (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 record contained an order for Diclofenac 1%, 2 grams. Apply to BLE, LBP twice daily. There was not evidence that LBP was in the policy for an acceptable and allowable abbreviation.