Every finding on record at Comfort Aid Hospice Care Corporation

Upon patient record review, 2 of 14 (Patient #2,#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 Patient #1: Home visit uncovered patient had multiple empty medication bottles and no updated medication profile in home binder. Agency was able to correct by Team member taking updated medication profile to patient home and Pharmacy delivered medications post visit @ 1200. The following medication bottles were empty in home, Ariprazole 15mg, 1 tab in AM, not listed on medication profile in patient binder. Escitalopram, 20mg, 1 tab in AM. Senna 8.6mg, 2 tablets daily. PRN. Carvedilol 3.125mg, 1 tablet, Daily. Clopidogrel 75mg, 1 tablet daily and not listed on in home medication profile. Patient #2: Home visit uncovered patient had multiple empty medication bottles and no updated medication profile in home binder. Agency was able to correct by Team member taking updated medication profile to patient home and Pharmacy delivered medications post visit @ 1200. The following medication bottles were empty in home, Aspirin 81mg, one tablet daily. Olanzapine 2.5mg, 1 tablet at bedtime. Losartan 50mg, 1 tablet daily in AM. Quetiapine fumarate 25mg 1 tablet, two times daily.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Skilled Nursing Frequencies do not reflect daily wound care visits, measurement documented upon admission with no other measurements on visits 4/24/24, 5/01/24 and 5/07/24. Agency was unable to produce wound care policy and has added to performance improvement plan.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #7: SN documented patient elevated BP and pain level 8/10. Pt reported taking morning BP medication and SN had patient take an additional BP medication of unknown specific drug. SN waited 30 minutes and was still elevated. Documentation was not detailed with specific information, or any interventions completed for pain and unresolved elevated BP of unknown values. Only stated elevated BP.

Upon patient record review, 2 of 14 (Patient #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 medications and treatments. Patient #4: Records indicate wound care order initiated upon start of care on, 4/17/24 was incomplete. Order did not contain who was managing wound, teach and train family with dressing changes due daily. Patient #5: Records indicate evidence that patient was in auto accident prior to admission and was admitted on to services with left sided arm fracture with staples in cast. No documentation of who is managing surgical wound and no updates on progress or plan for surgical wound