Every finding on record at Careplus Palliative, Inc.

Upon patient record review 1 of 5 (Patient #3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3: No evidence of an initial spiritual assessment.

Upon patient record review, 2 of 5 (Patient #1, #2) 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 did not contain Vitamin D3 and Glipizide, as identified during home visit that the patient was taking. Pepcid 20 mg PO BID was on the medication profile. The patient was taking Pepcid 20 mg PO BID as needed for dyspepsia as identified during the home visit. Patient #2: The medication profile did not contain lidocaine patch for pain management as identified during home visit that the patient was taking.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care.

Upon patient record review, 1 of 5 (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 comprehensive nursing assessment and subsequent assessments indicated the patient had a poor appetite and eating approximately 25-50% of meals. There were no problem statements with goals or interventions on the plain of care to address the condition.

Upon patient record review, 2 of 5 (Patient #1,2) 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 medications and treatments. Patient #1: The patient was taking Vitamin D3 and Glipizide, as identified during home visit, and there was no order for either medication. Pepcid 20 mg PO BID was ordered. The patient was taking Pepcid 20 mg PO BID as needed for dyspepsia as identified during the home visit. Patient #2: The patient had a lidocaine patch for pain management as identified during home visit that the patient was using but did not have orders.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 indicated the patient received a bed, wheelchair, and shower chair. There was no evidence the plan of care included the equipment needs of the patient. Patient #2: The medical record indicated the patient received bed, wheelchair, walker, and shower chair. There was no evidence the plan of care included the equipment needs of the patient. Patient #3: The medical record indicated the patient received bed, cane, and walker. There was no evidence the plan of care included the equipment needs of the patient. Patient #4: The medical record indicated the patient received walker. There was no evidence the plan of care included the equipment needs of the patient. Patient #5: The medical record indicated the patient received walker, nebulizer, and suction. There was no evidence the plan of care included the equipment needs of the patient.

Upon patient client record review, 1 of 5 (Patient #2) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: There is documentation in the medical record that the patient has a diagnosis of Senile degeneration of the brain and is disoriented X3.The hospice election does not identify the relationship of the person that signed the election or indicate a reason why patient was not able to sign.

Upon patient client record review, 2 of 5 (Patient #3, #4) 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: Documentation by the social worker indicated that the patient lives with family. It was determined the patient lives in a residential facility. Patient #4: Documentation by the RN indicated that the patient was a DNR. Documentation by the social worker indicated that the patient was a full code. The POLST indicated the patient wishes were cardiac resuscitation.